Hypnosis in Obstetrics
Indications and advantages of hypnosis in obstetrics
The induction of hypnosis in a patient is a very simple procedure; only a moderate amount of skill is needed to produce the trance state. Consequently, the physician can use it on almost all obstetrical patients. He needs to understand, however, that psychodynamic orientation is important because the constant interpersonal relationship between physician and patient is such that there is a marked emphasis of it in the hypnotic state.
One of the indications for using hypnosis is the understanding that respiratory and circulatory infection in the mother and baby with resulting anoxia is markedly decreased, perhaps even avoided altogether by the reduction or elimination of chemical anesthesia. Hypnosis also raises the resistance to muscular efforts. The fatigue that one frequently sees in the obstetrical patient in labor is therefore markedly minimized.
Whenever use of a chemical agent is contraindicated by virtue of a cardiac condition, tuberculosis, prematurity, etc., hypnosis may be used without fear of anesthetic danger to either the mother or the baby. It is generally accepted that any of the anesthetic agents used retard uterine activity; hypnosis does not. Another indication of the usefulness of hypnosis is that it can be controlled; if the hypnoanesthesia needs to be lightened or deepened, it can be readily accomplished by a simple suggestion on the part of the physician. When chemical or anesthetic agents are used, one can only counteract them by other drugs, by oxygen, or by time.
It is believed that capillary blood loss is diminished by hypnosis. This is probably due to a vasospasm or to some unknown effect on the coagulation time. Some experimental work has investigated this subject, but no definitive results have yet been attained. It is sometimes stated that bleeding can be stopped by use of hypnosis. This is questionable. The most one can expect is some sort of vasospasm, owing perhaps to a contracting of muscles along the capillaries and thus a diminishing of the bleeding in those areas. The claim has been made that bleeding in the sockets of the teeth can be stopped, but there again, it is probably by one of the two means mentioned above.
Another indication for the use of hypnosis is the reduced time element affecting both physician and patient. Previous antiquated methods used to induce hypnosis in obstetrics required the obstetrician to spend an excessive amount of time with the patient. He spent many hours training his patient to be a somnambulistic subject and developing anesthesia. When she went into labor, he had to hurry to the hospital to reinduce both the trance state and the anesthesia and remain with his patient all during her labor. It is understandable that obstetricians were not willing to use such a time-consuming method.
Changes in hospital attitudes and achievements by contemporary workers in the field have made the situation different today. Some hospitals, fearing legal difficulties, have prohibited the use of hypnosis. They have not been able to legislate against using hypnosis in the office, however. A use of posthypnotic suggestion and autohypnosis has therefore been evolved. The patient does her own hypnotizing in the hospital.
Actually, of course, using the recent techniques that have been devised, the time is considerably shortened. For example, the patient is comfortable during labor and therefore does not require the constant attention of her physician. Labor in primiparae is shortened by an average of two hours in the first stage; during the second stage, the patient is able to bear down more readily without extreme discomfort and expulsion can be augmented.
One other valuable indication is that with hypnosis there have been no reports of an increase in operative interference or of danger either to the mother or baby because of increased instrumental manipulation. These facts differ from the reports on almost all the other anesthetic agents.
An important point to bear in mind is that complete hypnoanesthesia may not be obtainable in a great many patients. But where a lesser amount of hypnoanesthesia is produced, as in light or medium hypnosis, there is still a marked reduction in the quantity of chemical anesthetics required. In every patient, therefore, in whom even a light or medium trance is produced, beneficial effects may be produced. This should include 95 to 100 per cent of the obstetrical patients. At the very least, the amount of chemical anesthetic agent the patient needs during labor is diminished with hypnosis.
Another good reason for using hypnosis is the postoperative comfort the mother is able to attain. She may be totally free of pain and, through this added comfort, the possibility of atelectasis and other dangers is also minimized or avoided.
Some obstetricians have reported that they can increase the secretion of milk in parturient patients by utilizing hypnosis and directly suggesting the filling of the breasts, or even better, by indirectly suggesting the feeling of well-being in the patient, with the mother looking forward expectantly to the wonderful child that she will be able to hold in her arms. Psychologically, this seems to cause an increase in the milk secretion.
Disadvantages of hypnosis
A primary disadvantage is the lack of training in hospital personnel. The patient enters the labor room and hears a woman across the hall or in the next room or even in the next bed crying out with pain. This upsets her and tends to break down her hypnoanesthesia. Similarly, a nurse or intern coming in to ask “How are your pains?” may bring back to her the idea of pain. This argument actually need not be considered too seriously. A patient who has been properly trained in the doctor’s office, will understand that those things may happen, that some people have not had the advantage she has had of learning a technique. Also, patients properly trained hypnotically learn to understand that when the intern or nurse says “pain,” what he or she actually means is “contraction,” and are able to minimize the effect of the words on their hypnoanesthetic state.
The combined approach
The idea of using a combined approach of hypnosis and a chemical agent is the important consideration to keep in mind. Hypnosis is not an “all or nothing” principle. A physician should not utilize only those hypnotic patients capable of the somnambulistic state in which they can produce a complete and total anesthesia, and claim that these are the successes and that all the other obstetrical patients are failures. Hypnosis should be made available to every patient. Some will require no chemical anesthesia, others will require 10, 20, 50, or even 90 per cent as much as they would have required if they had not learned hypnosis. But even when the amount of anesthesia is reduced only 10 per cent, the patient is being treated in a better manner.
Patients should be allowed to learn other phenomena of hypnosis besides those of anesthesia and analgesia. The new learnings will assist in making the labor more comfortable so that the patient will look forward to the birth of the baby with less consternation.
The first visit
What follows is a step-by-step account of the author’s procedure in utilizing hypnosis in obstetrics. At the first visit, the question of hypnosis is merely mentioned to the patient. If she knows little about the subject, she is given a booklet entitled, “An Old Art Returns to Medicine.”1 At the next visit, sufficient time will be allotted to cover the subject in a comprehensive manner.
The second visit
The initial discussion evolves around removal of the misconceptions of hypnosis. It is pointed out to the patient that she will not be asleep, that the hypnotized patient is not unconscious. The hypnotized patient can hear, feel, smell, sense, talk, and move around.2
Following the removal of misconceptions by pointing out to the patient that she will not be asleep, that she will hear everything that is important, that she will feel relaxed, and that she will feel comfortable the patient should be advised that she can learn to eliminate extraneous distractions and become capable of focused concentration.
The percentage of people who go into a light trance, medium trance, and deep trance might be mentioned at this time for the patient must recognize that not all people can develop complete and total anesthesia. Also, the availability of chemical agents during labor should be mentioned. This must be done carefully. If one says to a patient, “In case this doesn’t work, you will be able to get a chemical anesthetic agent,” one is certainly giving a very negative suggestion, and the probabilities of failure increase. A physician does not advise a patient, “If this doesn’t work, there will be other medications.” One merely tells her the truth, and the truth is that she can learn hypnoanesthesia and hypnoanalgesia, and her unconscious mind can recognize that this is a different feeling, a different sensation, and during labor, her unconscious mind can recognize, too, that it might want to compare the difference between this type of anesthesia and analgesia and chemical anesthesia or analgesia, or even no anesthesia or analgesia. Should her unconscious mind decide to test this difference, it is perfectly permissible. Once having made the tests in any way it chooses, the unconscious mind will select the one that it likes best, and immediately the patient can utilize that technique. This should be very carefully told to the patient so that she accepts the idea that should she awaken from the hypnotic state or if the hypnoanesthesia wears off, or if she would like to try no anesthesia or a shot or a “whiff” of gas, she may do so. At the same time, it should be made clear that she need have no guilty feelings about this idea, that she need not think she has failed for this is a perfectly normal situation that occurs frequently in many obstetrical patients.
Another point to be made at this meeting with the patient is that hypnosis is a teaching procedure; all the physician does is to teach the patient what to do. There is no possibility that the physician can fail. The doctor might say: “I have taught hypnosis for many, many years to hundreds of patients. Most patients are able to learn hypnosis very easily and very readily. Some patients learn it more slowly than others. There are different ways to gain knowledge. In learning to use a typewriter, some girls learn by listening to music as they type away at the keys; others learn by chewing gum very vigorously as they type; still others learn by keeping their eyes closely peeled to the typewriter. But as they are learning, most of them learn by making errors, by going back and correcting the errors, by indelibly implanting within their unconscious that particular error, and then proceeding with their learning.”
The physician might continue with a discussion of the learning curve. This should be explained as simply as possible. “The learning curve is one of an ascending line, a leveling off, a little descending line, ascending again, a little plateau, a little descending, and so on. And that is the way you learn.” As these things are being pointed out, the patient is acquiring a tremendous amount of knowledge to which she is entitled.