The application of hypnosis to the expectant mother at risk for premature delivery

MISSING IMAGE

Material Information

Title:
The application of hypnosis to the expectant mother at risk for premature delivery
Physical Description:
viii, 125 leaves : ; 28 cm.
Language:
English
Creator:
Knudson, Marshall L., 1952-
Publication Date:

Subjects

Subjects / Keywords:
Hypnotism in obstetrics   ( lcsh )
Premature infants   ( lcsh )
Genre:
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1984.
Bibliography:
Includes bibliographical references (leaves 115-124).
Statement of Responsibility:
by Marshall L. Knudson.
General Note:
Typescript.
General Note:
Vita.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 000473823
notis - ACN9032
oclc - 11698206
sobekcm - AA00004894_00001
System ID:
AA00004894:00001

Full Text














THE APPLICATION OF HYPNOSIS TO THE EXPECTANT
MOTHER AT RISK FOR PREMATURE DELIVERY




BY

MARSHALL L. KNUDSON


A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA


1984













ACKNOWLEDGEMENTS


Many individuals have supported and encouraged me during my

academic career. In expressing my gratitude, I also express my respect.

I wish to thank Dr. Joe Wittmer, the chairman of my doctoral

committee for his support and encouragement, and especially for his help

in the final stages of this work.

To Dr. Paul Schauble, I wish to offer special gratitude for his

consistent support, thoughts, skills, directiveness and friendship that

has carried me through these years. To Dr. Harry Grater, my heartfelt

thanks for his patience with and trust in me.

This study was based upon work done through Shands Department of

Obstetrics and the Women's Clinic. I wish to acknowledge Dr. Amelia

Cruz's support for this project, and to acknowledge the incredible

amounts of time and energy which Ms. Linda Jones gave to make this study

a reality. To Alice Martin I give my thanks and appreciation for being

such a dedicated and independent therapist with the hypnosis subjects.

I also wish to acknowledge Dr. Bill Werner for his pioneering work in

obstetrical hypnosis and express my gratitude to him for his thoughts

and support throughout this project.

I wish to acknowledge the technical assistance I received from

Marie Dence, Vicki Turner, Peggi Sanborn, and Maggie Bielling in my data

analysis and last minute typing.







To Fred and Donna Desmond, I have special gratitude for their

varied skills in helping to turn out this finished product.

I owe a special debt of gratitude to my friends and colleagues at

the Alachua County Crisis Center. To Liz Jones, my special thanks for

giving me the flexibility and support I've needed these last five years.

I reserve special acknowledgements and loving gratitude to my wife,

Laura, for her support and understanding that allowed this to finally

happen, and to my parents, Donald and Jane Knudson, who have supported

me throughout my life.













TABLE OF CONTENTS



ACKNOWLEDGEMENTS.................................................. i

LIST OF TABLES......................................................... vi

ABSTRACT........................................................vii

CHAPTER

I INTRODUCTION........................ .............1

Rationale for the Study...........................4
Statement of the Problem........................6
Importance of the Study...............................7
Definition of Terms..................................8

II REVIEW OF THE
LITERATURE....... ...............................11

Prematurity and Medicine............................11
High Risk Mothers....................................14
The Demise of Hypnosis in Obstetrics................. 21
Psychological Approaches to High Risk Pregnancies....28
Three Psychological Methods Used in Obstetrics.......32
Hypnosis in Obstetrics...............................35

III METHODS AND PROCEDURES............................ ..43

Hypotheses..........................................44
Population..........................................44
Procedures........................................... 46
Treatment Programs .................................48
Instrumentation......................................51
Data Analysis.......................................52
Limitations............... ....................... 52

IV RESULTS......... .............. ...............54

Sample...................................54
Findings Related to Null Hypothesis.................61






iv







V SUMMARY, LIMITATIONS, DISCUSSION OF RESULTS,
CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR
FURTHER STUDY...........................................76

Summary.............................................. 76
Limitations........................................ 76
Discussion of Results................................78
Conclusions.......................................81
Implications........................................ 81
Recommendations for Further Study...................83

APPENDICES

A CREASY'S RISK OF PRETERM DELIVERY SCORING SYSTEM........86

B INFORMED CONSENT FORM................................87

C HYPNOSIS GROUP PROTOCOL ....................................89

D SESSION SUGGESTIONS.................................102

E PRENATAL CARE.......................................104

F STUDY DATA FORM.............. ............... .............106

G CASE NOTES ON THE HYPNOTIC SUBJECTS...................110

REFERENCES.................... .................................115

BIOGRAPHICAL SKETCH...............................................125













LIST OF TABLES


TABLE Page

1 Sample Size and Descriptive Statistics Breakdown by Age.......56

2 Descriptive Statistics for Parity............................57

3 Analysis of Variance: Cruz High Risk of Preterm Delivery
Scale by Group....................................58

4 Analysis of Variance: Creasy High Risk of Preterm Delivery
Scale by Group......................................... ..59

5 Duncan's Multiple Range Test: Cruz High Risk of Preterm
Delivery Scale...............................................60

6 Analysis of Variance: Gestational Age Measurement by Group...62

7 Duncan's Multiple Range Test: Gestational Age Measured by
Group................ ............ .............................. 63

8 Chi-Square: Preterm vs. Term Pregnancy Measurement by Group..65

9 Mean Birthweights of Infants by Group (in Grams).............67

10 Analysis of Variance: Infant Birthweights by Group.........68

11 Chi-Square: Low Birthweight Measure by Group.................69

12 Analysis of Variance: Apgar at One Minute Scores by Group....70

13 Analysis of Variance: Apgar at Five Minutes Scores by Group..71

14 Analysis of Variance: Perceived Hours of Contractions by
Group...................................................73

15 Mean Hours of Perceived Contractions by Group................74

16 Chi-Square: Use vs. Non-use of Anesthetic Agents During
Delivery by Group..............................................75













Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment
of the Requirements for the Degree of Doctor of Philosophy

THE APPLICATION OF HYPNOSIS TO THE EXPECTANT
MOTHER AT RISK FOR PREMATURE DELIVERY

By

Marshall L. Knudson

April 1984
Chairman: Dr. Joe Wittmer
Major Department: Counselor Education

The purpose of this study was to examine the effects of hypnosis

and supportive counseling on pregnant women identified as high-risk for

premature delivery. The identified variables assessed included gesta-

tional age of newborns, birthweight, Apgar Scores, length of labor, and

anesthetic and analgesic agents used during the delivery process. A

hypnosis treatment, a supportive counseling treatment and a no-treatment

control condition were compared on terms of their effects on the various

pregnancy and delivery variables.

The sample consisted of forty-five expectant mothers who were

patients at Shands Obstetric Clinic in Gainesville, Florida, and had

been identified as "high risk" for premature delivery. Their ages

ranged from sixteen to forty-one.

Findings included significant increases in the length of gestation

among the hypnosis treatment and the supportive counseling treatment

groups as compared to the no-treatment control group. No significant

differences were found among groups in birthweights of infants, Apgar







scores, perceived hours of contractions, or use of chemical analgesic or

anesthetic agents.

The following conclusion was derived from data presented in this

investigation:

The psychological treatments of hypnosis and supportive counseling

both appear to significantly increase the gestations of mothers at a

high risk for preterm delivery.


viii












CHAPTER I
INTRODUCTION

"Prematurity is the greatest problem in obstetrics today, and a
multi-disciplinary approach will be necessary for its solution."
(Cavenaugh & Talisman, 1969, p. 521)

"Relatively little can be done during the course of pregnancy to
lower the perinatal mortality rate from environmental causes."
(Baird, 1977, p. 7)

Prematurity (gestation less than 37 weeks) and immaturity (birth

weight of less than 2500 gm.) are positively correlated and appear to be

responsible for a diversity of difficulties in infants. Lethal con-

sequences of prematurity have included stillbirths, abortions and neo-

natal deaths (Lillienfeld & Parkhurst, 1951; Knoblock & Pasamanick,

1962). Prematurity has been considered the most frequent cause of fetal

and neonatal death (Babson & Benson, 1966; Lee, Paneth & Gardner, 1980;

Tieche, Osborn & Broman, 1965).

The child that survives a premature birth faces an increased like-

lihood of being the victim of the following conditions: mental retar-

dation, epilepsy, learning disabilities, psychiatric disturbances,

minimal brain dysfunction, child abuse and neglect, cerebral palsy

(Babson & Benson, 1966; Caputo & Mandell, 1970; Fomufod, 1976). Thus,

although some 50,000 infants die each year due to low birth weight

(March of Dimes, 1979), some 220,000 other infants born premature or

with low birth weight face the threat of a host of adverse phenomena

(Von Mering, 1979).






No medical/physical explanations of premature labor have con-

sistently or adequately explained its occurrence in many (if not most)

cases of prematurity (Kazazz, 1965; Merrell Dow, 1981). The inability

to reduce effectively the rate of prematurity has, in large part,

relegated prevention to the nonmedical community. The variables identi-

fied as precursors to preterm deliveries are typically seen as socio-

economic and cultural factors which do not fall within the traditional

venue of medicine(Abramowicz & Kass, 1966; Babson & Benson, 1966;

Knobloch & Pasamanick, 1962; Niswander & Gorden, 1972; Pratt, Janus &

Sayal, 1977).

While less energy has been directed at these causes through medical

research and more energy has been focused on the intervention treatment,

a number of new variables have come to light. Interestingly, the socio-

economic status and physical factors of mothers correlated with their

rates of pre-term deliveries have masked the underlying psychological

factors that appear to consistently predict the likelihood of a high

risk pregnancy. These factors appear to involve the mothers emotional

instability and the added stress perceived in being pregnant (Blau,

Slaff, Easton, Welkowitz & Cohen, 1963; Caplovitz, 1963; Dohrenwend &

Dorhenwend, 1969; Gorsuch & Key, 1974; Gunter, 1963; Hollingshead &

Redlich, 1958; Ferreira, 1965; Kroger, 1977; Markush & Favero, 1974;

Negligan, Kolvin, Scott & Garside, 1976; Uhlenhuth, Lipman, Balter &

Stern, 1974). Life stresses without reciprocal life assets appear to

have a psychological base. Not surprising, then, is that the use of

psychological intervention during pregnancy of high risk mothers has

been empirically supported (Blau et al., 1963; Cavenaugh & Talisman,







1969; Javert, 1958; Mann, 1956, 1957; Nuckolls et al., 1972; Perchard,

1962).

The use of chemical anesthesia/analgesics has been argued against

consistently in cases of high risk deliveries (Kroger, 1977; Platonov,

1955). The feasibility of reducing the use of these agents appears

directly related to the psychological well-being of the patient.

Hypnosis has been shown to deal effectively with the anxiety, fears, and

pain related to the pregnancy and birth experience and also to reduce

the need for chemical anesthesia (Abramson & Heron, 1950; Cheek &

LeCron, 1968; DeLee, 1955; Hoffman & Kipenhaur, 1961; Oystragh, 1970;

Pascatto & Mead, 1967; Perchard, 1960; Werner, 1965). Yet, ironically,

it has been given little attention in medical literature in the last

decade. The argument against hypnosis in obstetrics appears to be based

on myths, misinformation and case studies outside the field of obstet-

rics involving irresponsible practices that disregard the fundamental

ethical and professional guidelines and principles of hypnosis (Fening,

1961; Hwyer, 1962; Jacobsen, 1954, 1959; Kroger 1977; Rosen &

Bartemeier, 1961; Tom, 1960; Werner, Schauble, & Knudson, 1982). In the

same way, the use of counseling/psychotherapy in obstetrics has been

relegated to a back-seat in traditional obstetric programs. Conversely,

these methods have shown promise in reducing prematurity and a variety

of deleterious side effects common on obstetric practice (Cheek, 1965;

Cheek & LeCron, 1968; Hartmen & Rawlins, 1960; Kroger & Freed, 1951;

Platonov, 1955; Schwartz, 1963, Davenport-Shack, 1975; Gorsuch & Key,

1974, Werner, Schauble & Knudson, 1982).

The Lamaze and Natural Childbirth methods have become accepted

components of prenatal care, perhaps because they down play their







psychotherapeutic and hypnotic qualities (Chertok, 1959, 1973; Heardman,

1948, 1959; Lamaze, 1958; Read, 1933, 1943, 1953). This makes them more

acceptable, but less effective in reducing complications of the birth

involving high risk mothers. The educational and physiological aspects

of pregnancy and childbirth are highlighted in these programs yet the

emotional/psychological state of the expectant mothers is less than

adequately dealt with or acknowledged.

The use of hypnotic approaches with high risk women appears to

offer new hope in the battle to reduce prematurity and increase the

likelihood of a safe, positive birth experience for both mother and

infant.

There appears to be little argument with the fact that the pre-

maturity in infants is a major concern within the medical field.

Disagreements occur among professionals, however, when it has been

suggested that the causes of prematurity may include psychological

factors which can be affected by psychological treatment methods direc-

ted toward the expectant mother. This research will be an attempt to

clarify the potential psychological variables in high risk expectant

mothers and offer intervention techniques in an attempt to reduce the

likelihood of premature deliveries.


Rational for the Study

The outcomes of premature births have been documented as to their

impact on the child, family, medical community and society. The inter-

vention treatment has been impressive, and in recent years the reduction

in neonatal deaths has been widely praised (Children's Medical Services

Statewide Program for Perinatal Intensive Care Centers, 1980).







Ironically, the actual incidence of premature deliveries continues to be

held relatively constant within our population (Chase, 1977), and while

the perinatal mortality rate decreases, premature deliveries are seen to

be associated with even greater percentages of perinatal deaths

(Quinlan, 1982; Rush et al., 1976). (As the medical literature con-

tinues to focus on physiological causes of prematurity, the data appear

to indicate that the physiological changes preceding and attendant to a

preterm delivery are often, if not typically, a reaction to less avidly

studied psychological factors.) For several decades, sporadic articles

have focused on these psychological factors and attempted to delineate

them. In reaction to these studies, a number of practitioners have

attempted to present prevention of preterm delivery treatment packages

which are based upon supportive psychotherapy and hypnotic approaches

(Cheek, 1965; Cheek & LeCron, 1968; Hartman & Rawlins, 1960; Kroger &

Freed, 1951; Platanov, 1955; Schwartz, 1963; Davenport-Shack, 1975;

Werner, Schauble & Knudson, 1982). The results appear to support the

concepts that stress reduction in the expectant mother and her positive

attitude toward pregnancy, childbirth and the infant will greatly in-

crease the likelihood of a full-term, uncomplicated birth experience.

During recent decades a variety of issues and misconceptions have

reduced the feasibility of direct preventative work and research on high

risk premature-delivery women using psychological modalities of treat-

ment. However, with the recent rise in the holistic medical movement,

and a greater mutual appreciation for interdisciplinary approaches to

complex problem areas, such merged treatment packages have become a

possibility.







It may be reasoned that the ever increasing medical sophistication

that the typical expectant mother faces has yet to offset (and in some

situations even intensify) feelings present within the woman which

negate the healthy development of the fetus. As her feelings become

more confused or repressed, the limitations of assets will eventually be

outnumbered by the stresses experienced by the woman. It might be

argued that any program that offers expectant mothers an opportunity to

become more relaxed and comfortable toward pregnancy, the fetus, and

later the child, would be of benefit by increasing her assets.


Statement of the Problem

The purpose of this study is to investigate the effects of hypnosis

and supportive counseling on pregnant women ascertained to be likely

preterm deliverers. The treatment approach will be examined in terms of

its effects on the variables of length of gestation, birthweight, chemi-

cal anesthetic/analgesic usage during delivery, perceived length of

labor by mothers, and neonatal physiological functioning. The treat-

ments involve a program of hypnosis, consisting of components involving

obstetric education, relaxation, imagery, and suggestions, and a program

of supportive counseling, consisting of contacts with a health pro-

fessional who can follow the pregnancy, offer support, and actively

answer questions and attempt to allay fears and concerns.

More specifically, this study will attempt to answer the following

questions:

1) Can psychological prevention strategies decrease the like-

lihood of preterm delivery;







2) Can psychological prevention strategies applied to

pregnant women impact on birthweight of their offspring;

3) Can the use of chemical analgesic/anesthetic agents

during delivery be reduced through psychological preven-

tions offered to pregnant women;

4) Can the self-preceived length of labor be changed

through the application of psychological prevention

strategies offered to women during their pregnancies; and

5) Will the physiological functioning of newborns improve as

a function of psychological prevention strategies offered

to women during their pregnancies?

Importance of the Study

This investigation may have important implications for the appli-

cation of psychological approaches to the field of obstetrics. A multi-

disciplinary approach, which includes the areas of physiological and

psychological functioning of both the expectant mother and fetus, will

require cooperation among a diversity of professionals. The collabor-

ation of such professionals may come to offer a patient population a

model of prevention, intervention, and aftercare that more fully

attempts attain a standard of mental and physical well being that can

have impact on the individual's total functioning. Perhaps even more

far reaching would be the opportunity to learn a system to continue the

process of self-awareness beyond the birth experience and throughout

one's life. Combined with the ability to identify personal stresses and

assets, such a program may impact not only the developing fetus, but

also on the developing child and family system.







Definition of Terms

The terms listed below are defined as follows for the purposes of

this study.

Immaturity involves infants born with a low birth weight (less than

2500 gm.) (Field, Sostek, Goldberg & Shuman, 1979).

Prematurity is a generalized term used for infants that are con-

sidered to be born prior to the optimal gestational period. The most

typical measurements for this condition involve birthweight and ges-

tational age at birth (Field et al., 1979).

Prenatal period consists of the time between conception and birth

(Funk and Wagnall's Standard Dictionary).

Neonatal period specifies the first 28 days after birth for the

infant. The term relates to the first "month" of the newborn's life

(Silverman, 1961).

Perinatal period extends from the 20th week of gestation through

the first week following birth. The term is used to signify the time

around and including the actual birth (Silverman, 1961).

Antenatal period involves the period of time prior to birth.

Antenatal denotes the developing period for the fetus and may signify

any conditions occurring in or to the fetus prior to birth (Funk and

Wagnall's Standard Dictionary).

Psychoprophylactic method (Lamaze method) is based on the work of

Velvosky and developed out of Pavlovian conditioning theory. The method

states that labor is not inherently painful, but rather a learned

reaction. The method is one of "relearning" and conditioning (Chertok,

1973; Hilgard & Hilgard, 1975; Lamaze, 1958).







Natural Childbirth (Grantley Dick-Read method) is based on the

fear-tension-pain concept. This implies that fear regarding labor

arouses tension which will then create pain when the contractions occur.

Treatment has been to offer expectant mothers significant quantities of

understandable information concerning the birth process and assurance to

the effect that labor does not have to be painful (Read, 1933, 1943,

1953).

High risk pregnancy identifies those cases where non-optional

factors or conditions related to the perinatal period are identified as

having potentially deleterious effects on the infants mental and physi-

cal condition. Prematurity has been consistently identified as a criti-

cal neonatal condition which drastically increases the likelihood of a

high-risk condition in the infant (Field et al., 1979).

Apgar score is a method of evaluating the neonatal status of the

infant. The method involves assessing five criteria (heart rate, res-

piratory effort, muscle tone, reflex irritability, and color) on a 0-2

rating scale, giving a possible total of 10 points. Scores are recorded

at one and five minutes after birth (Spellacy, 1976).

Direct suggestion involves an idea presented directly to the

patient with the hope that he will accept it uncritically and whole-

heartedly. Most of the suggestions used in the induction techniques are

direct suggestions (Florida Society of Clinical Hypnosis, 1980).

Trance is a term used to describe the hypnotic experience. The

word "state" may be used instead (Florida Society of Clinical Hypnosis,

1980).

Unconscious Mind is a concept which is useful for purposes of

explanation. For example, one may be trying to think of a name, saying







"It is on the tip of my tongue." A second later he remembers it.

Before the recall, the name may be said to be in his unconscious mind.

Another way of looking at the "unconscious mind" is to say that it

designates those experiences of the individual which are not at the

moment subject to verbalization (Florida Society of Clinical Hypnosis,

1980).

Hypnosis may be considered as follows: "Without attempting a

formal definition of hypnosis, the field appears well enough specified

by the increased suggestibility of the subjects following induction

procedures stressing relaxation, free play of imagination, and the

withdrawal of reality supports through closed eyes, narrowing of atten-

tion, and concentration on the voice of the hypnotist" (Hilgard &

Hilgard, 1975, page 8).

Trait Anxiety refers to relatively stable individual differences in

anxiety proneness (Spielberger, 1972).

State Anxiety is a transitory emotional state or condition of the

human organism that varies in intensity and fluctuates over time

(Spielberger, 1972).













CHAPTER II
REVIEW OF THE LITERATURE

The review of the literature in this chapter includes an

overview of 1) prematurity and medicine, 2) the high-risk mother

(socio-economic status, psychological, and stress factors),

3) hypnosis in obstetrics and 4) psychological approaches to high
risk pregnancies. In addition, relevant literature concerning

the demise of hypnosis in obstetrics and three psychological

methods used in obstetrics is also reviewed.


Prematurity and Medicine

Tieche, Osborn and Broman (1956) noted that among 1683 live

births they observed, some 8.26% of them involved premature

infants. By looking at the three most common causes of pre-

maturity (premature rupture of the membranes, toxemia, and

bleeding complications of pregnancy) they were able to explain

only 20% of the premature births. While they readily admitted

they could not adequately explain the causes of prematurity, they

also suggested that it is probably not preventable. Their recom-

mendations were toward further research and efforts directed at

the premature newborn and increasing the likelihood of survival

among this population.

While this study is more than two decades old, the recommen-

dations and suggestions appear to be consistent with present

statistics on prematurity. Chase (1977) in a review of U.S.







statistics on low birth weight infants between 1950 and 1974 found a

consistency in the rate which would suggest that efforts at the preven-

tion of prematurity have been minimal (or at least minimally effective).

Between 1960 and 1974, the rate of low birth weight infants to total

birth weight in populations has gone from 7.7% to 7.4% (with peak rate

of 8.3% in 1965 and 1966). An early study by Anderson and Lyon (1939)

noted that over 50% of premature births showed no obstetric or other

medical/organic cause.

In an attempt to explain prenatal mortalities, Baird and Thompson

(in Reed & Stanley, 1977) classified them as either of environmental or

obstetric etiology. While obstetric causes of prematurity include mul-

tiple births, toxemia, antepostum hemorrhage (spontaneous abortion or

placenta previa and abruptio placenta), and premature rupture of the

membrane (Silverman, 1961), the environmental causes are far less

clearly defined. Baird and Thompson considered environmental to mean

central nervous system malformations or low birth weight of unexplained

etiology.

Baird (1977) continues the earlier philosophy of limited preven-

tative medicine for prematurity when he notes that although much can be

done to reduce the obstetric perinatal mortality rate, "relatively

little can be done during the course of the pregnancy to lower the

perinatal mortality rate from environmental causes" (p. 7).

Fryer and Ashford (in Reed & Stanley, 1977) appear to also suggest

the lack of preventable causes of prematurity when they note that the

increased world-wide incidence of prematurity might best be explained by

"an accumulation of small effects rather than a single dominant factor"

(p. 5). Certainly the physiological and endocrinal changes occurring







during the process of fetal expulsion have been widely studied. How-

ever, the precipitating factors which create these changes continue to

be unresolved (Kazazz, 1965).

The intervention or treatment of prematurity or low birth weight

infants has made dramatic gains in the last decade. A recent study

shows the mortality rate among newborns in Florida to have dropped from

13.6 per 1,000 to 9.7 per 1,000 since the inception of neonatal inten-

sive care units in Florida in 1974 and 1975 (Childrens Medical Services

state-wide program for perinatal intensive care centers, 1980). While

these advances in treatment continue, the lack of investigation into

effective prevention methods remains puzzling. Rush and his associates

(1976) report that, apart from anomalous fetal development, 85% of

neonatal deaths are associated with preterm deliveries. Babson and

Benson (1966) noted that "a reduction of immaturity by the advancement

of fetal age must be the initial goal" (p. 10). They predicted that

the extension of pregnancy from 28 to 32 weeks might reduce the infant

mortality rate by as much as 65%.

The advances in medical science in the last decade have had a

dramatic impact on the mortality rate among high risk infants. However,

the actual rates of premature and low birth weight deliveries have been

consistent. While intervention techniques have received acclaim in

recent years, preventative measures have received limited attention or

been of limited value. The causes of prematurity continue to go unex-

plained by traditional medical models, yet answers may be found in the

realm of psychological factors.







High Risk Mothers

While the prevention of prematurity has made little headway in the

last two decades (Chase, 1971), a set of variables has consistently been

found in studies of women giving birth to premature infants.


Socio-economic status factors of prematurity

Pratt, Janus and Sayal (1977) noted that pregnant women who ran a

high risk of premature delivery included those who were young, poorly

educated, black, and non-seekers of prenatal medical care. Babson and

Benson (1966) found those women under 16 years of age, non-white, un-

married, obese, short, infertile, multipara over 40 years of age,

ignorant, poor, or disinterested in the pregnancy to be most likely to

deliver prematurely. Poor prenatal care, poor nutrition during preg-

nancy, smoking and drug use were also considered key variables (Miller

et al., 1978; Reed & Stanley, 1977).

Consistent with these findings have been the general indicators

that social class and prematurity are inversely related (Abramowicz &

Kass, 1966; Knobloch & Pasamanick, 1962; Niswander & Gordon, 1972).

That prematurity rates are highest among the lower class, of which a

disproportionate number are black women, under the age of 20, have

inadequate maternal nutrition, low levels of education, high rates of

illegitimacy and little or no prenatal care (Zax et al., 1977) would

certainly support the relationships. While the statistics indicate

higher prematurity rates among lower socio-economic status (SES) indi-

viduals, Douglas (1950) warned against assuming that this explained

prematurity simply as a socio-economic condition. Even in the highest

SES population, premature deliveries are still found (Rider et al.,







1955). While studies that simply split populations by socio-economic

status show the lower classes having significantly higher rates, in Dade

County, Florida, in the 1960's, the rate among private patients still

approached 7.5%, while indigent patients had rates approaching 15%

(Cavenaugh & Talisman, 1969). The often-noted variables suggested to be

linked with prematurity are poor prenatal care, illegitimacy, maternal

age, nutrition during pregnancy, smoking and drug use. All hold true

for the higher socio-economic classes as well as the lower classes

(Reed & Stanley, 1977; Miller et al., 1978). Lack of appropriate

medical intervention, so measured by inadequate prenatal care, has been

an oft-cited rationale for measured rates of prematurity. Pratt et al.

(1977) note the relationship between antenatal care and low birth weight

(LBW), and found some striking results:

Rate of LBW Newborns in Relation to Mothers First Seeking Prenatal Care

White Black Total

1st Trimester 5.1% 11.0% 5.7%
2nd Trimester 6.3% 12.1% 7.7%
3rd Trimester 6.3% 11.7% 7.8%
None 16.2% 25.6% 19.8%


While at first glance these statistics appear to confirm the re-

lationship between prenatal care and reduction of LBW, prenatal care

begun in the first trimester appears to have much less impact than

prenatal care begun in the third trimester. Pratt et al. (1977) offer

no explanation for these results, but it seems doubtful that these very

significant differences between late prenatal care and none are wholly

explainable by medical intervention. Findings which may shed some light

on this confusion included Butler and Alberman's (1969) study that, when







populations of married and unmarried women were matched on antenatal

care received, the prematurity rate among the unmarried women was twice

that of their married counterparts. It would appear that antenatal care

alone may not be the issue directly relating to the state of prema-

turity. Rather, the key precursors may relate more to the psychological

state of women and how these variables relate to willingness and

interest in attaining prenatal care. Poor antenatal care may better

indicate the emotional state of women' involvement and interest in the

pregnancy than lack of medical intervention as it relates to prema-

turity.

The focus on socio-economic status and physical factors may effec-

tively mask the underlying variables that separate premature and full-

term delivering mothers. Psychological/emotional rather than

physical/social status differences have been suggested as being more

directly linked to prematurely delivering women. Pierog et al. (1970)

noted that fully three times the number of infants born to unmarried

women were treated in intensive care units as compared to married women.

Of special interest was that the unmarried women were also found to be

of a higher socio-economic background than their married counterparts.


Psychological differences

In a retrospective study, Blau et al. (1963) found psychological

differences between 30 women with premature offspring and 30 full-term

infants. After matching these mothers on social class, education, race

and parity, they found the mothers of premature infants to more often

have negative feelings toward the pregnancy, unwillingly become preg-

nant, conscious feelings of hostility and rejection toward the







pregnancy, attempted inducing an abortion. These women were viewed as

more often being emotionally unstable, narcissistic, immature, young,

uncertain about their feminine identity and development, and harboring

uncertainties over their heterosexual and maternal state than the full-

term matched sample of women.

Consistent with these emotional indicators, Gunter (1963) found

that (in contrast to mothers of full-term infants) mothers of prema-

turely born infants more often express feelings of fear and inadequacy,

nervousness, anxiety, neglect or desertion by husbands, excessive depen-

dency on protective male, preoccupation with illness, feelings of imma-

turity and inadequacy as a female, rejection of heterosexual relation-

ships, and association of sex with feelings of guilt.

A variety of authors have noted various emotional states common to

premature delivering mothers as opposed to full-term mothers. Heardman

(1948, 1959) discussed poor upbringing and negative mental attitude

toward childbirth as key issues. Wortis et al. (1963) found premature 2

1/2 year old's mothers to be more apathetic, unhappy and depressed.

Negligan et al. (1976) found preterm mothers in comparison to full-term

mothers (matched on SES) to score higher on the Eysenck Neuroticism

Scale. Mann (1957) suggested that guilt over former premarital pregnan-

cies and induced abortions will lead to future problem pregnancies. Two

studies have pointed toward dreams and nightmares as playing a key role

in leading to spontaneous abortions and premature labors (Cheek, 1965;

Cheek & LeCron, 1968). Ferreira (1965) found prenatal environment and

maternal emotional factors to influence the cause and outcome of preg-

nancy.







In a rather limited, but fascinating study, Kazazz (1965) inter-

viewed 16 physically healthy, pregnant women, ages 15-37. From the

interviews, he rated each woman's attitude toward pregnancy as negative

(feelings of being victimized by the fetus), positive (evidencing com-

mensal feelings toward the fetus), or neutral (primarily focusing on the

potential newborn without showing undue preoccupation with the fetal

growth and development). He then predicted that women with negative

attitudes toward the fetus would have premature deliveries (more than 10

days early), women with positive attitudes would have post-term

deliveries (more than 10 days later than expected due date) and women

with neutral feelings would have term deliveries. On 13 of 16 predic-

tions he was accurate with a p <.0002. In another study noting pre-

existing psychological factors in preterm mothers, Zax et al. (1977)

noted markedly higher rates of prematurity among chronically depressed

and chronically schizophrenic women than in his normal controls.


Psychological stress

While a variety of emotional and psychological factors have been

identified as being consistent with increased rates of prematurity, the

concept of experienced stress in the preterm mother appears to be a

common underlying condition (Blau et al., 1963; Gunter, 1963; Ferriera,

1965; Negligan et al., 1976). Blau et al. (1963) note that the high

rates of premature births among black, primiparas, young unmarried

women, women with histories of problem pregnancies and negative atti-

tudes toward pregnancy are all good indicators of stress. The relation-

ship between social stress and social class had been shown to be

directly related with lower classes experiencing higher social stress







(Caplovitz, 1963; Hollingshead & Redlich, 1958). While Myers et al.

(1974) found the lowest social class to have twice the level of

psychiatric symptomology as the higher classes, the severity of sympto-

mology and stressful life events were found to positively correlate

(Dohrenwend & Dohrenwend, 1969; Markush & Favero, 1974; Srole, 1962).

Kramer (1957) noted a greater persistence of symptoms with fewer coping

skills among the lower classes.

Uhlenhuth and his associates (1974), when looking at the relation-

ship between life stress, symptoms intensity, and demographic variables,

found that higher stress and higher symptom intensity could be found

among unmarried, youthful, and lower social class individuals, three

variables considered consistent with high risk women.

Tupper (1960) noted that emotional stress and psychological dys-

function influence the duration of pregnancy. In the same vein, Gunter

(1963) noted that the stressful conditions of death, economic need,

interpersonal problems, and physical disabilities all increased in re-

lation to the rate of premature deliveries. Kroger (1977) suggested

that strong emotions and stress can create emotional spontaneous abor-

tions by tending to contract the uterine musculature and thus causing

premature separation of the placenta. Friedman and Neff (1977) note a

direct relationship between hypertension in mothers diastolicc blood

pressure greater than 85) and low birth weight offspring.

Gorsuch and Key (1974) studied the relationship between problem

pregnancies (low birth wieght, prematurity and birth defects) and life

change (stress) events prior and during pregnancy. Their findings (with

118 pregnant women) indicate that stressful events (including such

events as major personal injury or illness, death of spouse, marriage,







mortgage or loan less than $10,000, foreclosure of mortgage or loan, and

in-law troubles) all appear to have an impact on the pregnancy when they

occur during the last six months prior to the pregnancy or during the

pregnancy itself. During this time span, stressful life events were

most dangerous when they occurred during the last two trimesters of the

pregnancy. In the same study, Gorsuch and Key noted that increased

trait anxiety had no significant impact on rates of problem pregnancies,

whereas state anxiety, especially that related to the pregnancy,

appeared to have the most deleterious effect on pregnancy outcome.

Similarly, Schwartz (1977) found prematurity and low birth weight re-

lated to the mothers self-reported stress and anxiety during the preg-

nancy. In the review by McDonald (1968) further stress related factors

and birth complications appear to be empirically linked in the

literature.

Nuckolls et al. (1972) looked at both stressful life events and

protective psychosocial assets of pregnant women. Assets were noted in

the areas of self, marriage, extended family, social resources, and

definition of pregnancy (planned, feelings about pregnancy, antici-

pation, etc.). His findings indicate that when no recent stressful life

events had been experienced, the level of assets made no difference on

the outcome of pregnancy; however, when high levels of stressful events

were noted, 90% of these women with "weak assets" experienced birth

complications, while only 33% of those women with high stress but

"strong assets" experienced problem pregnancies.

It would appear that SES factors (poverty, poor nutrition, limited

prenatal care, etc.) have received much of the blame for prematurity in

recent years. However, underlying these conditions have been the







pervasive set of psychological factors including the attitude of the

mother toward the fetus, the mother's emotional stability, and her

general set of psychological assets as compared with her psychological

stresses. The literature suggests that these psychological factors may

be the central issues dictating whether a fetus is carried to term.


The Demise of Hypnosis in Obstetrics

While the literature of the 1950's and early 1960's appears to

offer hypnosis as an effective and appropriate adjunct to obstetrical

practices, in the last decade, research involving hypnosis in obstetrics

has all but disappeared. By 1960, a series of issues concerning the use

of hypnosis in obstetrics had been presented.

"Obstetricians do not have the time to use hypnotic techniques

with their patients." The use of excessive time demand on the physician

was cited by a number of authors (August, 1960; Fenig, 1961; Tom, 1960).

Others have refuted this criticism (Beaudet, 1963; Gross & Posner, 1963;

Kroger, 1959; Zuspan, 1960). Davidson (1962) noted that her hypnosis

patients used significantly less anesthesia and subjectively found labor

far more pleasant than their non-hypnosis counterparts. She suggests

that the time expense of hypnosis training (1 1/2 hours to train a group

of six women) was highly cost-efficient considering the objective and

subjective results. In comparing the potential benefits of hypnosis

with the actual demands placed on the staff dealing with the obstetric

patient, it would appear that arguing against hypnosis for this reason

is unfounded.

"Women who use hypnosis during delivery will miss out on the

experience of the birth since amnesia is part of the hypnotic trance."







Others have argued that hypnosis creates gross amnesia or clouds the

birth experience (Freedman et al., 1952; Jacobsen, 1954; Jacobsen,

1959). Disregarding the issue of amnesia or loss of awareness that

relates to the use of chemical anesthesia/analgesics, the use of hypno-

sis creating amnesia is directly questioned by Chertok (1959). He

points out that hypnosis can, but need not, involve amnesia for the

patient. Chertok suggests critics look as far back as Bernheim's work

at the turn of the century to find that amnesia need not be a part of

hypnotic state.

Hilgard (1979) suggests that the work of Puysequr in the 1700's may

explain the common misconception linking hypnosis and amnesia. Puysequr

noted post-amnesia following a trance state. Apparently, based on his

work, amnesia became a hallmark of hypnosis. Hilgard continues by

noting "It was thought for a time--and some still believe this to be

spontaneously amnesia for events within hypnosis. However, this may be

a result of expectations created by the folklore of hypnosis, and in

laboratory experimentation such spontaneous amnesia is very rare. .

(p. 52). Rather than hypnosis creating a loss of ability to remember

and be aware of the birth experience, there appears to be general agree-

ment that hypnosis can assist women in focusing their attention and

enhancing their experience during the birth process (Fromm & Shor,

1979).

"A woman who is hypnotized is unable to be truly relaxed, but has

instead lost her control and free will." Jacobsen (1954, 1959) argued

that relaxation techniques are positive and tend to cultivate self-

confidence, emotional stability and freedom of will. Conversely, he

suggests that hypnosis favors dominance by the therapist, that







perceptions and understanding are clouded and the patient loses

emotional freedom and independence. He argues that the hypnotized woman

is not relaxed, and that hypnosis is inherently dangerous.

Mandy et al. (1952) state simply that the state of relaxation and

of hypnotic trance are indistinguishable. Numerous authors (Buxton,

1957; DeLee, 1955; DeLee & Duncan, 1956; Kroger & DeLee, 1957; Werner,

1959) have noted that after delivery using hypnosis, women are relaxed,

show less post-partum exhaustion, and feel surprisingly well after the

delivery. Buxton (1962) suggests that one only needs to watch the

"relaxation" techniques employed by the antagonists of hypnosis to note

the "hypnotic effect" they have on the patient. There appears to be

general consensus among modern practitioners and researchers in hypnosis

that the subject simply learns a cognitive skill and gains more cogni-

tive control as she becomes involved in the hypnotic process (Fromm &

Shor, 1979). In fact, learning self-hypnosis is seen as a powerful ego-

building device.

Buxton (1962), in attempting to state the difference, suggested

that

A very persuasive, compelling and magnetic therapist may not

actually be practicing hypnosis in terms of strict definition of

these techniques but he may be having such a 'hypnotic effect' on

his subject that the latter is left in a state of suggestibility

which may have a great therapeutic value. Persuasive suggestion

may profoundly affect a patient's perception of, and reaction to,

the physiological processes of uterine contracting, cervical

dilation, and perineal distension which under ordinary circum-

stances would produce a severely unpleasant reaction which would




-T.


be interpreted as a sensation of pain. In a state of suggesti-

bility, a patient might interpret sensations differently (p. 53).

Thus, it appears that a patient's use of hypnosis offers them the

opportunity to learn how to better control her experience in such a way

as to be most productive for her.

"Hypnosis is very dangerous! Only a psychiatrist (or psychiatri-

cally trained physician) can use hypnosis without risking severe

psychiatric damage to his obstetric patient." The turning point for

hypnosis in obstetrics appears to relate to the American Medical

Association's suggestions published in 1958. After a two-year study of

the issue, the Council of Mental Health of the AMA supported the use of

hypnosis within the practice of modern medicine. However, they also

suggested that hypnosis be used only by those individuals "qualified" in

its proper use (Council on Mental Health, 1958). The issue of proper

training and severe consequences of "improper" training surfaced in 1960

following an article by Tom (1960). While his article noted the bene-

fits of hypnosis in obstetrics, the following editor's notes concerning

the dangers of hypnosis pointed out that "Tom's article is of particular

pertinence to our theme since he reports five cases in which psychiatric

hospitalization was required following hypnosis" (p. 29). Lost in the

ensuing discussions was the fact that the five cases in Tom's article

all involved a single physician, apparently using age regression to deal

with psychosomatic and psychiatric disturbances. None of the cases

involved obstetrics.

On February 15, 1961, the American Psychiatric Association issued

an official statement, titled "Training in Medical Hypnosis" which

included the following: "Hypnosis is a specialized psychiatric







procedure and, as such, is an aspect of doctor-patient relationship.

Hypnosis provides an adjunct to research, to diagnosis and to treatment

in psychiatric practice. It is also of some value in other areas of

medical practice and research." It continues by noting that "Whoever

makes use of hypnotic techniques, therefore, should have sufficient

knowledge of psychiatry, and particularly psychiatric dynamics, to avoid

its use in clinical situations where it is contraindicated or even

dangerous" (p. 3).

Their recommendations on training were that it should be at least

one half to one full day a week over nine to twelve months, be post-

graduate training (minimum of 144 hours), and be taught by a fully

qualified psychiatrist competent in the field of hypnosis. With these

restrictions, it is not surprising that obstetricians withdrew from

hypnosis and went back to chemotherapy.

Hwyer, at the April 30th, 1961, conference on psychophysical

methods of childbirth extended these stated limitations -by vehemently

arguing against the use of hypnosis for childbirth or anything else.

Hoffman and Kipenhaur (1961), in an attempt to clarify the limita-

tions of hypnosis in obstetrics, noted that the problems of hypnosis

related to cases in which alleged sexual inproprieties between the

patient and physician occurred. Although they suggest knowledge of

psychiatric dynamics and limitations of hypnosis to the area in which

the physician is trained, they also note that these guidelines should

alleviate any complications.

While actual cases which indicate dangerous consequences of hypno-

sis in obstetrics appear minimal, two psychiatrists, Rosen and

Bartemeier (1961), following on the heels of APA's position paper on







hypnosis in obstetrics, present one such case. They note an obese

patient having been taught self-hypnosis for a delivery. At some point

prior to the labor, they suggest, she moved toward a psychotic state,

and during hypnotic sessions believed she had been sexually assaulted by

her physicians. Following the delivery, she became paranoid of her

physician. Following the case presentation, their final judgements are

that the inadequately trained hypnotist (physician) will cause more harm

than benefit to their patients. Whether this case sufficiently demon-

strates the need for extensive and labored training in hypnosis is

highly questionable.

Perchard (1962) in advocating the use of hypnosis in obstetrics and

dealing with the potential psychological danger of hypnosis in

obstetrics suggests that "except in a psychiatrically ill patient and in

the patient who gives a history of psychiatric illness or behaves in a

way which suggests an abnormal personality, there seems to be no abso-

lute contraindication to the use of hypnosis in either obstetrics or

gynecology" (p. 23).

In a more reasonable vein, Kroger (1977) has noted the key poten-

tial problems and realities of hypnosis to include

1. Only one quarter of women can achieve a deep enough state for

it to be the sole anesthetic.

2. The induction can lose power through distraction of the screams

of other women in labor or prior discussions by others that it

won't be effective.

3. It takes time. However, group hypnosis seems to deal some with

the issue.







4. Unless autohypnosis is used, the therapist needs to be present

during labor.

5. Misconceptions about hypnosis make induction ineffective or

more difficult for many women.

6. It is contraindicated in severely disturbed, psychotic/border-

line cases. However, these women are unlikely to be hypno-

tizable.

7. There is a danger of inappropriate statements or poor relation-

ships with clients being damaging. However, this is true in

non-hypnotic conditions as well.

8. Some contend that hypnosis is dependency fostering. This may

be true, but it is temporary and true for doctor/patient rela-

tionships in general. Also, autohypnosis may reduce this.

The position papers of both the American Medical Association and

the American Psychiatric Association noted the potential benefits of

medical hypnosis. However, the stress upon potential psychiatric damage

through its use and the conservative stance concerning extensive

psychiatric training needed by physicians using hypnotic techniques

appear to have discouraged continued research in the potential efficacy

or hypnosis with an obstetric population. Certainly, obstetricians

faced with the task of extensive psychiatric training in order to

satisfy APA's guidelines on the use of hypnosis might understandably opt

for the more traditional medical approaches to obstetrics in which he or

she has already been trained. Thus, while the literature of the 1950's

and early 1960's offers hypnosis as a potentially powerful tool in

obstetrics, more recent literature often all but neglects its existence.

It is perhaps not surprising that hypnosis as a treatment modality in







obstetrics has been downplayed. So have other psychological factors and

treatment approaches in obstetrics also seen less discussion in the

literature. In more recent texts on obstetrics, focusing on high risk

pregnancies and prematurity, psychological issues are often mentioned

only in passing or completely disregarded (Babson et al., 1980; Black,

1972; Crosse, 1971; Field et al., 1979; Klaus & Fanaroff, 1979; Reed &

Stanley, 1977).


Psychological Approaches to High Risk Pregnancies

As has been noted previously, the work of Nuckolls et al. (1972)

found a direct relationship between prematurity in infants and their

mothers experienced levels of stress during pregnancy. When the mothers

expressed high levels of stress without having counterbalancing levels

of emotional/psychological assets, the probability of premature birth

increased dramatically. The outcome of this study was to predict that

by reducing the stresses or increasing the psychological assets of a

mother, that prematurity rates could be reduced. Cavenaugh and Talisman

(1969) offer another rationale for psychological training during preg-

nancy when they note that the prematurely born infant is in the greatest

danger of fetal depression and delivery trauma, and yet the mothers of

premature infants are typically the least prepared (psychologically)

antepartum for a low-anesthesia delivery which is vital to these

infant's well-being. Blav et al. (1963), after noting an extensive list

of emotional problems common among prematurely-delivering women, urged

that "mental supportive therapy" be offered these women during their

pregnancies. The suggestions appear to focus psychological treatment

packages for high risk pregnant women in two directions to reduce the







incidence of prematurity and to increase the likelihood of trouble-free,

low anesthesia, lessened stress delivery for the high risk infants. The

three major ingredients presented appear to be educational programs to

help clarify the gestation process to the mothers, counseling to help

the mothers deal with stress and reduce anxiety arising from or during

the period of pregnancy, and hypnotic approaches to alleviate underlying

irrational fears, increase relaxation and reduce the need for anes-

thetics.

Perchard's (1962) study appears to focus on the benefits of educa-

tion and the added benefits of hypnosis for the pregnant woman. His

results show that the attitudes concerning childbirth are more positive

and the use of anesthesia reduced in women who received education over

those who did not. However, he goes on to say that on these same

outcome measures, the women who received education and hypnosis fared

best of all groups. Others (Kubie, 1953; Ransom in Buxton, 1962) have

pointed toward the oversimplification of the educational processes.

Their concern has been that although the educational process of child-

birth and its physiology will help to reduce undue anxiety and the

tension and thus reduce its pain, it also my act to mask what can be

called "neurotic anxiety" which will still be present. Thus childbirth

may still be a highly painful experience.

Kubie notes that one needs to be aware that education is important,
but that psychotherapy approaches will allow women to deal with the

neurotic or irrational anxiety or beliefs. This would be especially

important for those women who may need a chance to work through the

fears that may be brought out or surface during educational programs.

Similar arguments are presented by Cheek and LeCron (1968) where they







suggest that the fears of delivery are no longer socially acceptable

since women are educated to the facts of childbirth which include the

lessened dangers and death rates to both mother and infant in modern

medical facilities, antiseptic conditions, highly trained personnel,

chemoanesthesia, etc. Thus, any underlying fears are no longer as

openly discussed but instead may surface through psychic or physio-

logical disturbances. They suggest that many premature births may be

examples of the underlying fears which are not dealt with through tradi-

tional education programs for expectant mothers.

The work of Mann (1956, 1957) appears to directly impact on the

notions that underlying emotional states may be at issue in many preg-

nancies terminating prematurely. Working with 39 women who had repeated

spontaneous abortions, he noted that of 168 pregnancies among the group,

92.9% had ended in spontaneous abortions. Following supportive-therapy

counseling during pregnancy, only eight (20.9%) of the 39 pregnancies

ended in spontaneous abortions. The treatment offered supportive care

and supportive psychotherapy to women early in their pregnancy. He

suggested that guilt concerning the pregnancy or prior pregnancies was a

central issue, and much of the counseling focused on absolving the guilt

and offering the patients a warm, caring, non-judgemental atmosphere.

Of interest were the eight women who did not carry to term in the study.

Mann noted that the abortions occurred in the second trimester of preg-

nancy, after the women had experienced movement of the fetus, at which

time the women appeared to withdraw or become unresponsive to the

supportive measures, while also becoming more dependent upon the staff.

Javert (1958) replicated Mann's findings and also presented results







which showed 80% of the women who had been identified as habitual

spontaneous aborters carrying to term following prenatal psychotherapy.

As previously noted, the benefits of hypnosis in the reduction of

need for anesthesia during labor and the emotional support and positive

attitudes that women receive as a consequence of prenatal hypnotic

training appear to suggest hypnosis as a psychological asset to pregnant

women as well (Buxton, 1957; DeLee, 1955; DeLee & Duncan, 1956; Kroger &

DeLee, 1957; Spiegel, 1963; Werner, 1959). This asset may help to

balance the emotional stresses that appear related to spontaneous abor-

tions and premature labors. Kroger (1977) suggests that strong emotions

and stress can contract the uterine musculature, thus causing premature

separation of the placenta. Kroger and Freed (1951) and Platonov (1955)

both present cases where premature labors have been terminated through

hypnosis. They suggested that the premature labors are induced by

dreams and nightmares which are the outcome of unconscious fears.

Hartman and Rawlins (1960) show similar results in a case of abruptio

placentae where hypnosis was used to prevent the premature labor.

Schwartz (1963) presents similar findings using hypnosis to terminate

premature labor. Common to these studies were the use of hypnosis to

allow the patient an opportunity to become aware of the reasons for the

premature labor and to deal with the irrational fears underlying the

contractions.

The application of hypnotic and counseling techniques to women

considered at high risk for premature delivery appears to be consis-

tently supported in the literature.

Whether through asset-building approaches of supportive counseling,

reduction of anxiety and tension through hypnotic approaches, or







reducing stress from rational or irrational fears through a combination

of psychological methods, there appears to be a need for a systematic

study of extension of these approaches into the field of preventative

medicine in obstetrics.


Three Psychological Methods Used in Obstetrics

While hypnotic techniques in obstetrics have received lessened

attention in recent years, two other psychological pain reduction

methods have continued to flourish, "The Natural Childbirth" methods of

Grantley Dick Read (Read, 1933, 1943, 1953; Heardman, 1948, 1959; Thoms,

1950) and the psychoprophylactic techniques of Platonov, refined by

Velvowski, and then objectified and popularized in the United States by

Ferdinand Lamaze (Chertok, 1959; Chertok, 1973; Platanov, 1955). The

approaches all have consistently addressed the issues of painful child-

birth and all have suggested the psychological component of pain and

psychological methods for its reduction. The methods vary in their

philosophical foundations and theoretical make-up, yet their commonali-

ties in practice may suggest a central core of factors that make them

positively accepted and beneficial to women using them during pregnancy

and childbirth.

The psychoprophylactic methods appear to date back to Platonov's

work in 1923. Platonov suggested that "hypnosuggestion" would allow for

chemically free deliveries among women. His techniques became popular-

ized in Russia with 60% of women not using any anethesia/analgesic

during labor (Hilgard & Hilgard 1975). In 1951, Velvowski reintroduced

Platonov's work which was quickly picked up by Lamaze.







In 1952, Ferdinand Lamaze brought the work of Velvowski to France;

"L'accouchement sans douleur" or "Childbirth without Pain" was based

upon Pavlovian concepts of conditioned reflex training which enables a

patient to block painful sensation by providing a counter-stimulus at

the appropriate time. Buxton (1962) notes that "lectures are given such

that patients will be put in a cheerful frame of mind, that motherhood

enriches their lives with a new and beautiful meaning, and statements

should be made concerning the contribution which they are making to

their environment" (p. 29). Lamaze objectified the approach and made

its teaching specific while carefully interpreting suggestions through-

out the training. The teaching includes what happens in the course of

"normal pregnancy", the Pavlovian thesis of relieving pain by elimina-

ting fear, respiratory exercises, neuromuscular control through relaxa-

tion, and the appropriate responses during labor and delivery. Training

involves active participation of the mother and often the father

(Hilgard & Hilgard, 1975).

Read's "Natural Childbirth" approach appears based upon the assump-

tion that pain during delivery is a pathological response rather than a

physiological (Read, 1933). Read (1945) noted that fear appeared to be
the main cause of pain during childbirth and the concept of "a tense

mind means a tight cervix" was presented. Read's hypothesis involves

the concept that the fear is a byproduct of society's view of childbirth
as a terrifying experience and the fear leads to tension which creates

the pain experienced during labor and delivery. Simply speaking, he

suggests that eliminating the fear, apprehension and tension by changing

the psychological attitudes of women toward labor and delivery will

reduce or eliminate the pain experienced (Read, 1933; 1943; 1953).







Read's (1953) approach is based upon three major tenets of

training: the factual instruction on childbirth, physiotherapeutic

practices--relaxation and breathing exercises, and psychological methods

which instill confidence through suggestion.

It is of interest to note that both Read and Lamaze indicate the

uses of suggestions during their training, and yet, both strongly deny

their use of hypnotic methods. This may be explained by the fact that

neither approach uses formalized induction methods and both indicate the

belief that the patient is responsible and in control during the labor

sequence. That these factors do not fit the stereotype of hypnosis does

little to separate them from the hypnotic process. The commonalities

between Read, Lamaze and hypnotic approaches for childbirth are

striking. All utilize and believe in the importance of relaxation,

controlled breathing, and reassurance regarding the woman's ability to

manage the stress to be experienced (Hilgard & Hilgard, 1975). While

Mandy, Mandy and Farkas (1952) and August (1960) both have noted that

the relaxation techniques of Lamaze and Read are indistinguishable from

the hypnotic state, this is not to say that their impact on clients is

identical. Samko and Schoenfeld (1975) predicted that the hypnotic

susceptibility of patients would relate to their success with Lamaze

training. Results of patients attitudes and obstetricians ratings of

patients success with Lamaze showed no difference in relation to their

hypnotic susceptibility, thus indicating that deep levels of trance need

not be evident or occur for Lamaze method to be effective (In this

study, 14% of the women used strong analgesics--twilight sleep or

general anesthetic). However, looking once more at Davidson's (1962)

study comparing autohypnosis patients and physiotherapy-controlled-


w-







breathing patients, the patients using hypnotic methods showed signifi-

cantly less use of analgesics/anesthetics. These studies may indicate

that while deep trance states need not be necessary for more efficacious

outcome of the labor process to occur, when hypnotic approaches are

applied they are more effective than the other methods of relaxation.

It appears somewhat ironic that although hypnotic techniques offer

the mother consistently equal or greater levels of comfort, control,

relaxation and freedom from pain as the two other approaches mentioned

in this section, it has been the least publicized or accepted approach.


Hypnosis in Obstetrics

The use of hypnotic techniques in obstetrics goes back more than a

century. However, with the use of inhalation anesthesia, interest and

use of hypnosis to control pain during labor fell out of general use

(Chertok, 1959; Kroger, 1977). Not until the 1950's did the use of

hypnosis begin to reappear in the obstetric literature (Kroger, 1960;

Moya & James, 1960; Spiegal, 1963; Tom, 1960; Winklestein, 1958; Zuspan,

1960).

Kroger (1977) has suggested a variety of reasons for the re-emer-

gence of hypnosis in obstetrics. The primary benefits noted for using

hypnosis with obstetric patients have included

1. Reduction of fear, tension and pain, before and during labor

with consequent rise in pain threshold.

2. Reduction of chemoanalgesia--anesthesia given to patients, with

reduction of undesirable post-operative effects due to medica-

tion (for both mother, fetus, and subsequently, the child).

3. Control of painful uterine contractions.







4. Decreased shock and speedier recovery following delivery.

5. Increasing the patient's resistance to fatigue, thus minimizing

maternal exhaustion (relates to length of labor).

6. Benefits to mothers by allowing them to experience the

delivery.

Reduced need for chemical anesthesic/analgesia

Perhaps the most common rationale for the use of hypnosis has

involved the reduction in pain for the mother during labor, thus re-

ducing the need for chemical anesthetics. As early as the 1920's

Platanov (1955) noted that hypno-suggestion in Russia was commonplace,

and because of its benefits, fully 60% of the deliveries were performed

without the use of chemical anesthetics. While Kroger (1977) suggested

perhaps only 0% of women would find hypnosis sufficient as the only

anesthesia during labor, he added that another 50% would benefit through

hypnosis by allowing for a reduced amount of chemical anesthesia to be

administered. Tom (1960), in a study utilizing 73 women undergoing

delivery with the aid of hypnosis, reported that 40% needed no other

form of anesthesia. He went on to note that "regardless of the results,

all but one of the patients thought that hypnosis was worthwhile and a

great help during labor, and all wanted to use hypnosis again for their

next delivery." Davidson (1962) compared 70 women who used autohypnosis

with 70 women using physiotherapy--controlled breathing and 70 women

considered as controls (no prior training in anesthesic/analgesia

methods for childbirth). She found that 59% of the autohypnosis

patients required no chemical anesthesic/analgesic, while only one of

the controls and none of the physiotherapy patients went without some


ww







chemical agents (p< 001). Rock at al. (1969) suggested that even with

untrained women who have their first encounter with hypnotic techniques

during labor, significantly fewer need chemical anesthesic during the

delivery than their control counterparts. August (1960) reports com-

plete success with hypnosis as the sole anesthetic agent with 93.5% of

his sample and reports success using hypnosis supplemented with other

anesthetic agents in 6.5% of his sample. In another study, August

(1961) reported 58% of those who underwent hypnosis required no chemical

analgesic. Mosconi and Starcich in Crasilneck and Hall (1975) report

excellent results using hypnotic analgesia in 79% of their sample, and

Mody in Crasilneck and Hall (1975) reports an average success rate (no

chemical anesthesia) of 75%. Sixty-two percent of a group of women

receiving hypnotic training during the antepartum period were delivered

successfully with hypnosis as the sole anesthesia in a study reported by

Gross and Posner (1963).

A diversified number of studies has consistently supported the

hypothesis that hypnosis reduces the need for other anesthetics during

labor by reducing the perceived pain in the mother (Cheek & LeCron,

1968; Coulton, 1960; Coulton, 1966; Kline & Guze, 1955; Malyska &

Christenson, 1967; Mellgren, 1966; Oystragh, 1970; Pascatto & Mead,

1967; Perchard, 1962; Werner, 1965). Hoffman and Kipenhaur (1961), in

their review of the literature on hypnosis in obstetrics, found hypnosis

to consistently be found to eliminate or greatly reduce the experienced

pain of childbirth, with the effectiveness ranging in differing studies

from 35-90%, with a median of 50%.







Reduction of anxiety

A corollary to pain reduction through hypnosis may be the anxiety

experienced prior to and during pregnancy. Read (1945) suggested that

"A tense mind means a tense cervix." Just as hypnosis has reduced the

experienced pain in labor, it has also been shown efficient in dealing

with the attendant anxiety (Abramson & Heron, 1950; DeLee, 1955;

Greenhill, 1960; True, 1954). Spiegel (1963) stressed that emotional

support derived through the use of hypnosis during the prepartum period

benefitted the women. The uniformly positive results of hypnosis during

labor have been tied with the positive attitudes expressed in these

women. These patients have been identified following delivery as more

relaxed, not experiencing as much post partum exhaustion and generally

feeling surprisingly well after delivery in comparison to women not

having used hypnosis (Black, 1972; Buxton, 1957; DeLee, 1955; DeLee &

Duncan, 1956; Kroger & DeLee, 1957; Werner, 1959).


Reduction of Operative Techniques

Kroger's (1977) assertion that hypnosis aids in the reduction of

operative techniques has been supported through Davenport-Shack's (1975)

work as well as Reynolds et al. (1954) research. Davenport-Shack (1975)

note that the training itself may help create optimal conditions for

delivery (and thus reduce operative techniques) by teaching the expec-

tant mother how best to behave during labor. Reynolds et al. (1954)

demonstrated that hypnosis appears to have the potential to alter the

contractive patterns during labor. They noted that the changes appeared

to move toward the most efficient types of contractions for delivery

following hypnotic induction.







Buxton (1962) notes that it is common observation that women who

have deliveries with almost complete anesthesia routinely suffer 1-2

days of post-partum depression assumed to be a small price for the use

of pharmacologic agents to reduce the pain. However, he also noted that

following deliveries where the patients were conscious and participated

in labor and were able to see immediately the outcome (completion of

delivery), post-partum depression was not experienced. While use of low

spinal, epidural, or canal anesthesia eliminates this problem, it in-

creases the number of force deliveries (Buxton, 1962; Heardman, 1959).

Buxton argued that we must expect some misfortunes that are just part of

this mode of delivery. Still it seems hard to argue with non-chemical

anesthesia and still meet Adair's (1940) goal of obstetrics:

The practice of obstetrics is the art and science of properly

caring for the fetus and the women during the performance of

childbearing to the end that the structures, function, health

and lives of both mother and offspring may be conserved and

preserved and the best interests of the individual, the family

and the human race be furthered (p. 12).

Kroger (1977) notes very simply that while there is always a risk to

both mother and infant when chemical anesthetics are used, that hypno-

anesthesia appears to be 100% safe in comparison. Cavenaugh and

Talisman (1969) suggest that the greatest problems of chemical anesthe-

tics involved the fetal depression it can create and the increased

incidence of delivery trauma. Again, hypnoanesthesia is considered to

significantly reduce concerns over these side effects.


Vl







Affecting length of labor

As a method of reducing the length of labor, hypnosis has received

significant study. A number of authors (Cheek, 1957; Kroger & DeLee,

1957; Michael, 1952; Winklestein, 1958), in simple studies comparing

patients using hypnosis during labor and those who did not, found the

average length of labor to be some 2 hours shorter for the mother using

hypnosis. Heardman (1959) looked at 800 cases all trained in relaxation

methods (Dick-Read). When compared with untrained women matched by age

and parity, significantly shorter labors were were noted among the

trained population. Abramson and Heron (1950) report an average de-

crease of 3.23 hours in Stage 1 labor in primiparas trained with hypno-

sis; they report an average decrease in the first stage of labor of 1.79

hours for multigravidas. Mellgren (1966) reports an overall reduction

of labor by 2 to 3 hours, and Davidson (1962) supports a reduced length

of Stage 1 labor following hypnosis training as compared to untrained

control or trained physiotherapy-controlled breathing patients. Only

minimal variation between hypnosis patients and controls is reported by

Gross and Posner (1963) for Stage III labor and average total length of

labor, though length of labor appears significantly decreased in Stage I

and Stage II in women trained with hypnosis. Studies by Perchard (1962)

and August (1960) suggest no significant differences in length of labor

between groups of women who have received hypnosis training and those

who have had no special training.

At the same time, studies investigating the influence of hypnosis

on length of labor have not dealt with the significant question: "When

does labor really start?" While most studies have found shorter labors

in women using hypnosis, this may merely be an artifact of the lack of







discomfort typically reported by those same women. If labor is depen-

dent upon the self report of the expectant mother, then women who con-

tinue to be in a state of comfort and control may prolong the reported

onset of "labor."

In fact, Werner believes that hypnosis may actually prolong the

duration of Stage I labor. Werner reports his experience that

"deliveries in the hypnotic state are not remarkable for their rapidity,

and that a calm, unhurried labor is the result of a relaxed, fearless,

happily expectant patient" (Werner et al., 1982, p. 22).

The continued struggle to reduce the impact of prematurely born

infants in the medical community has been most consistently aimed at

interventions involving the newborn. This research is an attempt to re-

identify the potential benefits of preventative measures which may

actually reduce the probability of preterm deliveries. It is suggested

that psychological intervention such as hypnosis may offer expectant

mother a myriad of benefits.

As the contraindications for the use of chemical anesthesia become

more evident in obstetrics, the use of hypnosis as an adjunct or alter-

native to chemical anesthesia may regain its popularity of the past.

Hypnosis may allow the expectant mother to experience the delivery

more fully, relatively free from unnecessary anxiety and pain, and the

infant to experience delivery with a reduced likelihood of undergoing

operative procedures or chemical agents which might impair his or her

new-born life.

The research continues to identify strong correlations between

psychological factors and the probability of premature delivery. This





'IL


research is an attempt to offer the expectant mother psychological

assistance in her endeavor to deliver a full term infant.













CHAPTER III
METHODS AND PROCEDURES

This study attempted to ascertain the relationship between the

extension of pregnancy and the application of hypnosis techniques to the

mothers at risk for premature delivery during the last five months of

pregnancy. An experimental design was used with the expectant mothers.

Dependent measures included the length of gestation at birth, birth

weight, the amount of anesthetic- analgesic drugs used during the

delivery by the mothers, Apgar scores of newborns (standard test of

newborn's functioning one minute after birth, administered and scored by

the attending physician), and the length of labor as perceived by the

women.

Three groups of pregnant women were identified: an experimental

group including women receiving instruction in hypnosis, a supportive

counseling group with the women receiving supportive interactions in

lieu of hypnotic inductions, and a control group receiving no special-

ized services.

This chapter describes the hypotheses which were tested, a des-

cription of the population being studied, sampling procedures, instru-

mentation, procedures, experimental treatments, data analysis, and

limitations of the study.







Hypotheses

1. There is no difference in the gestation period of infants born

to mothers who complete either a hypnosis program, a supportive

counseling program, or who receive no treatment.

2. There is no difference in the birth weight of infants born to

mothers who complete either a hypnosis program, a supportive

counseling program, or who receive no treatment.

3. There is no difference in use of anesthetic/analgesic drugs

during the delivery of infants born to mothers who complete

either a hypnosis program, a supportive counseling program, or

who receive no treatment.

4. There is no difference in Apgar scores in infants born to

mothers who complete either a hypnosis program, a supportive

counseling program, or who receive no treatment.

5. There is no difference in the perceived length of labor by

mothers who complete either a hypnosis program, a supportive

counseling program, or who receive no treatment.


Population

The population for this study was expectant mothers who were

patients at Shands Obstetric Clinic who had been identified as "high

risk" for premature delivery by the staff and had been identified as

"high risk" for premature delivery by the assessment instrument de-

veloped by Creasy, Gummer, and Liggins (1980).

This population included women screened for high risk in all Shands

Obstetric Clinics as well as in the Ocala Health Department Clinic.

Women excluded from this study were patients who were "private"







(patients who had hired a specific physician to offer them prenatal care

at Shands). Thus, the research population was predominately lower SES

women, many who were receiving Medicaid, Federal Funds, or various

financial grants. The Clinic staff suggests that some 90% of these

patients were identified as lower SES individuals, receiving financial

assistance, with approximately 65% of the patients being black. The

patients on the average were in their early 20's, with women's ages

ranging from the early teens to early 40's.

All clinic patients (as opposed to private practice) that were

identified by Shands staff as potential "high risk" candidates had their

records evaluated by staff using the Creasy et al. assessment instru-

ment (Appendix A). Women with scores of 10 or greater on this instru-

ment who were also identified as 22 weeks or less advanced in their

gestation were eligible for this study.

Women accepted as subjects after the initial screening were

assigned to the hypnosis or supportive counseling condition dependent

upon whether their hospital record number was either odd or even, re-

spectively.

All subjects talked with a Shands staff member concerning this

research and signed an informed consent statement (Appendix B) prior to

any treatment. A control group was also identified involving a retro-

spective sample of women identified as high risk for premature delivery

by Creasy's instrument. Individuals in the control group were indi-

viduals not assigned to an experimental group by 22 weeks gestation.

Two experimental and one control group were formed, making the total

number of subjects in the study to be 45.







Procedures

Following the initial screening by staff and the application of

Creasy's instrument, those women eligible for this study met with an

Obstretics Fellow to discuss their possible involvement in this study.

The identified staff member is a registered nurse who also holds a

master's degree in psychology. She routinely meets with these patients,

and for this study talked with them at their next scheduled clinic

appointment following identification.

During these meetings between the Shands staff member and the

patients, patients read or were read the informed consent form, out-

lining the conditions imposed upon both control and experimental sub-

jects. Any questions were answered at that time. Patients signing the

form were advised of their status in the research and continued to be

followed by the staff member throughout their pregnancy, regardless of

which condition they were assigned to.

Those subjects assigned the hypnosis condition began seeing a

researcher/counselor during clinic visits when their gestation fell

between 16 and 22 weeks advanced. Traditionally, these "high risk"

women are scheduled for appointments every two weeks by clinic staff.

Thus, the four session experimental condition spanned six to seven

weeks.

A four session treatment program was identified for the following

reasons:

1. The study was an attempt to make a significant change in medi-

cal outcome with a minimum of interference in the traditional

medical prenatal care model.







2. The selected population has a high incidence of "no-shows" for

clinic appointments which necessitates a limited number of

projected sessions with these individuals during their pre-

natal visits.

3. Various researchers have noted that a limited series of

hypnotic sessions can positively impact on obstetric patients

(Beaudet, 1963; Cheek & LeCron, 1968; Gross & Posner, 1963;

Davidson, 1962; Kroger, 1959; Zuspan, 1960).

4. For the form of "non-traditional" intervention to be accepted

by the medical community (and probably the public at large) it

must clearly be seen as cost efficient from a limited time

investment standpoint.

5. A clear precedent has been established by the highly popular

short courses offering women "Natural Childbirth" or "Lamaze"

techniques in the Country. Typically, these courses only meet

a maximum of six times in the last weeks of pregnancy.

Counselors for the hypnosis condition met the following re-

quirements:

1. Be a counseling psychologist or a doctoral candidate in either

counselor education or counseling psychology;

2. Have had prior training in hypnosis/relaxation work;

3. Be familiar with the literature on hypnosis and obstetrics.

Consultation and supervision for this experimental condition were

offered by Dr. Amelia Cruz of the Shands Obstetrical Staff and Dr. Paul

Schauble of the University Counseling Center.






Subjects were assured by the interviewer during the initial

screening interview that all information would remain confidential and

that the data would be used only for the purposes of this research.

Treatment Programs

Experimental (Hypnosis Group). A four session sequence was offered

to women in the experimental group. These women had the experience and

learned the methods and benefits of hypnosis to increase the likelihood

of a safe, full term, relatively pain-free delivery. Sessions focused

on the process of hypnosis and inductions, multiple opportunities to

experience and practice a hypnotic induction and experiencing the deep

relaxation capable through hypnosis, the conceptualization of pregnancy

during the various stages or trimesters while induced, suggestions

directed toward the women during the hypnotic state for the fetus to be

carried to full-term emphasizing the benefits to mother and infant,

suggestions during hypnosis for the application of the techniques and

benefits of the hypnotic state throughout pregnancy and delivery as well

as at other stressful or exciting periods in their lives. The sessions

were in a progressive sequence.

Session One. Session One offered women an introduction to the
process of hypnosis, a videotape of an actual induction with pregnant

women, an explanation of the pregnancy process including the birth

experience and typical medical procedures, an opportunity to begin

personally to learn and experience an induction for relaxation.

A detailed description of the Session One format is found in Appen-

dix C including transcripts of the introduction, explanation of hypno-

sis, induction and pregnancy education talk.







Following the videotape presentation, the subject had an oppor-

tunity to ask questions concerning the tape she just viewed. Following

this, she was given a chance to learn and experience the relaxation

techniques described and presented in the tape. The same induction

format was utilized (the educational component was deleted).

The suggestion was made that if she would like to practice this

technique between sessions, it would be beneficial to her, her preg-

nancy, and her offspring.

Sessions Two, Three, and Four. Each successive session had three

primary goals for the participants:

1. An opportunity for continued practice to learn more fully and

develop the auto-hypnotic process and its benefits;

2. A method and opportunity for abbreviating the inductions pro-

cedure into a shorter, more effective package;

3. New suggestions (listed in Appendix D) that focused on issues

of comfort with pregnancy, reduced anxiety over pregnancy and

delivery, carrying to term, and general health of both mother

and child. These suggestions were offered while the subject

was experiencing the trance state.


Supportive Counseling Group. Women assigned to this group received

supportive interactions with an identified Shands staff member in lieu

of hypnotic sessions as identified for the hypnosis program subjects.

Each woman thus received quantitatively equivalent attention during

clinic visits as did women in the experimental condition. The inter-

actions between the women and the staff member were aimed toward

supportive counseling, with the general goals being to answer any







questions the woman may have had concerning her pregnancy; to identify

concerns she may have been experiencing; to offer appropriate advice and

direction concerning any medical complications; to offer a supportive

atmosphere to the woman during her clinic visit. Specifically, the

following points were covered during sessions with each woman:

1. The teaching of self-detection of painless contraction by

palpation.

2. The instructions to report immediately if

a) uterine contractions are in a regular pattern, with or

without pain, occurring for one hour.

b) dull low backache, pressure or pain persist.

c) intermittent lower abdominal or thigh pain is experienced.

d) intestinal "cramping" with or without diarrhea or indiges-

tion is experienced.

e) change in vaginal discharge (bleeding or increased mucus)

is noticed.

3. To consistently answer any questions the patient may ask, as

well as eliciting questions and offering information,

especially concerning such issues as

a) specific medical issues involving when labor may begin,

what procedures may be used, why a cerclage may be suggested,

etc.

b) future pregnancies and possible attendant problems.

c) questions related to drugs being taken or administered.

d) when delivery can occur without harming the offspring.







4. To offer a comfortable, relaxed atmosphere in which the preg-

nant women are attended to without undue interruption during

their interaction.

5. To actively elicit and support conversations and discussions

concerning the patients feelings about their pregnancy, their

family members, their family situation (including financial),

their feelings and concerns about the expected child, and their

plans--both immediate and into the future.

6. To offer appropriate feedback, support and advice concerning any

or all of the aforementioned issues.


Control Group. Women in this condition were not offered any

specialized treatment or procedures as part of this research project.

They received all typical and appropriate treatment offered by the

clinic. A listing of these medical treatment packages can be found in

Appendix E.


Instrumentation

The instrument used in this study was Creasy's Risk of Preterm

Delivery Scoring System, developed by Creasy, Gummer, and Liggins

(1980). The RPD scoring system is based upon factors such as past

reproductive performance, socio-economic status, medical history, and

current pregnancy complications identified in the pregnant patient.

These various factors are weighted and the cumulative score assigned to

each subject is based upon the number of variables noted in that

subject. Women with scores of 0-5 are placed in a low risk category,

women with scores of 6-9 are considered medium risk, and women with







scores of 10 or greater are considered high-risk of delivering pre-

maturely (less than 37 weeks gestation).

Research by Creasy et al. (1980) involved assessment of 966 preg-

nant women at their first prenatal visit. Of these 691 (72%) were

identified as low risk by the RPD, 186 (19%) were identified as medium

risk, and 89 (9%) were identified as high risk for preterm delivery by

the instrument. Between 26-28 weeks gestation, retests were done on all

women. Retests showed that 904 (93.6%) of the women remained at their

previously identified level of risk for preterm delivery, with 62 (6.4%)

of the women being evaluated at a higher isk for preterm delivery. The

outcomes of the pregnancies showed 59 (6.2%) of the women delivering

prematurely. Among the low risk mothers, 12 (2%) delivered prematurely;

of the medium-risk mothers, 9 (5%) delivered prematurely; and of the

high-risk mothers, 38 (30%) delivered prematurely (X (2) = 18.07,

p < .001).

Data Analysis

A randomized control group post-test only design was used.

Subjects were assigned to one of the three groups. Following deliveries

of women, data were collected using the form identified in Appendix F.

The data were analyzed with analysis of variance procedures being

applied. To assess each hypothesis, the three scores for each outcome

measure were compared. If significant at the .05 level, multiple com-

parison methods were applied.

Limitations

This study may be limited due to the population and issues being

examined. This research worked with pregnant women at high risk for







premature delivery, and applied techniques that continue to be con-

sidered outside "traditional" medical practice. By working exclusively

with a clinic population, these types of subjects historically have

poorer rates of using medical care than private patients, as well as

having fewer economic resources, less education, lessened support sys-

tems, and misconceptions concerning childbirth and pregnancy. These

factors make them poor risks for treatment, especially the poor atten-

dance and lessened interest in seeking prenatal care. It may also be

that the restrictions imposed by the actual number of contacts with

these women negate any possible benefits of the treatment approaches.


ww












CHAPTER IV
RESULTS


This study sought to examine the effects of hypnosis and supportive

counseling with pregnant women identified at a high risk of delivering

prematurely. Two treatment approaches were examined and compared in

terms of differences reported on measurements of length of pregnancy

(gestation), birthweight, newborn functioning (Apgar scores), perceived

length of labor by the mother, and type and amount of chemical

analgesics and anesthetics used during the delivery process. A control

group was also used for comparisons. The Statistical Analysis System

was used for the analysis of variance, Chi-square analyses of scores and

means procedures on the selected measures and on the demographic

variables. The acceptable level of significance for all analyses was p
< .05.

Sample

The study initially included 56 women who were patients of the

Shands Hospital Obstetric Clinic and identified as high risk for preterm

delivery. Nineteen percent of the potential subjects did not meet the

requirements of the study, leaving a total of 45 women who completed the

program. The non-completion-of-study rate for the hypnosis group was

29%; 8% of the supportive counseling subjects did not complete the

study; 19% of the control subjects did not complete the study.

Table 1 provides descriptive statistics for the sample by age.

Subjects ranged from 16 to 40 years of age. The mean age for all







subjects was 25.2. All subjects had a history of prior pregnancies

(multi-gravid).

Table 2 presents descriptive statistics for parity. Within the

total population, the mean number of term deliveries was .8, with a

range of 0 to 4; the mean number of premature births stood at .64 with a

range of 0-3; the mean number of abortions being 1.1 with a range of

0-6; and the mean number of living children being 1.0 with a range of 0-4.

All subjects in the study were identified as high risk candidates

for preterm delivery by the Cruz and Creasy scoring systems. The mean

Cruz score for all women was 4.5, with a range of 1-8. The mean Creasy

score was 13.5 with a range of 10-24. Tables 3 and 4 indicate the

analyses of variance conducted for these two measurements, respectively.

The analysis of Creasy scores showed no significant differences.

Conversely, Cruz scores did show a significant difference, with the

control subjects scoring significantly lower (lessened risk) than the

hypnosis or supportive counseling subjects.

Table 5 reveals the results of a Duncan's Multiple range test to

identify where the variance among groups on the Cruz variable were

found. Results show that while the hypnosis and supportive counseling

groups did not differ significantly, both had significantly higher Cruz

scores than did the Control group. These results indicate that the

controls were initially evaluated as lower risks for preterm delivery by

the Cruz measurement than the experimental populations. However, no

significant differences in risk of prematurity were identified among

groups by the Creasy instrument.

Subjects were randomly assigned to the hypnosis, supportive coun-

seling, and control group as discussed in Chapter III.












Table 1

Sample Size and Descriptive Statistics Breakdown by Age


Sample Group: Hypnosis Supportive Counseling Control

Sample Size
12 12 21


Age

Mean 26.0 26.6 23.8

Minimum 18.0 16.0 17.0

Maximum 34.0 35.0 40.0

Range 16.0 19.0 23.0













Table 2

Descriptive Statistics for Parity


Sample Group: Hypnosis Supportive Counseling Control

Term Deliveries

Mean .83 .83 .76

Minimum 0.0 0.0 0.0

Maximum 2.0 2.0 4.0


Premature Deliveries

Mean .66 .58 .76

Minimum 0.0 0.0 0.0

Maximum 2.0 1.0 3.0


Abortions

Mean 1.1 1.4 .85

Minimum 0.0 0.0 0.0

Maximum 6.0 3.0 3.0


Living Children

Mean .9 .8 1.15

Minimum 0.0 0.0 0.0

Maximum 2.0 2.0 4.0















Analysis of Variance:


Source


Model

Error


Corrected Total

Source


GRP


Table 3

Cruz High Risk of Preterm Delivery Scale
by Group


DF Sum of Squares Mean Squai


2 19.72 9.86

41 118.72 2.90


43 138.44

DF Type I SS F Value PR F


2 19.72 3.40 .04


re















Analysis of Variance:


Table 4

Creasy High Risk of Preterm Delivery Scale
by Group


Source DF Sum of Squares Mean Square


Model 2 0.47 0.23

Error 41 560.53 13.67


Corrected Total 43 561.00

Source DF Type I SS F Value PR F


GRP 2 0.47 0.02 0.98













Table 5

Duncan's Multiple Range Test:
Cruz High Risk of Preterm Delivery Scale


Duncan Grouping Mean N Group


A 5.42 12 Hypnosis
A
B A 5.00 12 Supportive Couns.
B
B 3.90 20 Control







Analyses of variance were computed to determine any differences

among groups regarding the variables of age and parity. No significant

differences were revealed. Results of the analyses suggested no signi-

ficant differences among groups on demographic variables.


Findings Related to the Null Hypotheses

Differences between women involved in the hypnosis group, suppor-

tive counseling group, and the control group were examined in terms of

pregnancy outcome measures. Findings regarding the null hypotheses

follow below:

Hypothesis 1 There is no difference in the gestation period of

infants born to mothers who complete either a hypnosis program, a

supportive counseling program, or who receive no treatment.

Gestational age as identified by Obstetric clinic staff in the

mothers' record was used to assess differences in lengths of pregnancy

between the groups. Weeks of gestation ranged from 20 to 41 in the

entire sample. Table 6 presents an analysis of variance for gestational

age in the three conditions. A significant difference was obtained,

indicating that the control subjects had significantly shorter

gestations than the hypnosis or supportive counseling subjects. Table 7

presents the results of a Duncan's multiple range test, identifying

where the differences in gestational ages between groups were located.

Both the hypnosis and the supportive counseling group subjects were

found to have significantly longer gestations than subjects in the

control group. No significant difference was found between the

gestations of subjects of the hypnosis and supportive counseling groups.

This result suggests that women involved with the hypnosis or supportive


VI













Table 6

Analysis of Variance: Gestational Age Measurement by Group


Source DF Sum of Squares Mean Square


Model 2 91.59 45.79

Error 42 561.39 13.36


Corrected Total 44 652.98

Source DF Type I SS F Value PR F


GRP 2 91.59 3.43 0.04













Table 7

Duncan's Multiple Range Test:
Gestational Age Measurement by Group


Duncan Grouping Mean N Group


A 39.33 12 Supportive Couns.
A
B A 38.42 12 Hypnosis
B
B 36.10 21 Control







counseling treatments benefited through these approaches by averaging

longer pregnancies than the subjects in the control group. However, no

significant differences were found between the two experimental condi-

tions regarding the length of pregnancies.

Table 8 presents the results of a Chi-square test to determine

whether there were significant differences in the numbers of preterm

(less than 36 week gestations) as opposed to term (equal to or greater

than 36 week gestations) in the hypnosis, supportive counseling, and

control groups. The Chi-square test indicated no significant differ-

ences among the groups on this measurement.

Based upon the obstetrical records data that gestational age was

significantly increased'in the hypnosis and supportive counseling

conditions as opposed to the control condition, hypothesis 1 was

rejected at the .05 level of confidence.

Hypothesis 2 There is no difference in the birth weight of infants

born to mothers who complete either a hypnosis program, a suppor-

tive counseling program, or who receive no treatment.

Obstetrical records of each subject indicated their offspring's

measured birthweights in grams. Birth weights ranged from 460-4050

grams. Table 9 presents the mean birth weights of infants in each

group. Table 10 presents the results of an analysis of variance which

was done to determine if there were differences between the birthweights

of infants born to subjects in the hypnosis, supportive and control

groups. Significant differences in birthweight were not found among

groups. In order to ascertain whether significant differences had

occurred in the number of low birth weight infants (<2500 grams), as

opposed to considered non-low birthweight (>2500 grams) among groups,













Table 8


Chi-Square:


Preterm vs. Term Pregnancy Measurement by Group


Group .Preterm Term Total
(< 36 wks.) (>.36 wks.)

Hypnosis

Frequency 1.00 11.00 12.00
Percent 2.22 24.44 26.67
Row Percent 8.33 91.67
Column Percent 14.29 28.95

Supportive Counseling

Frequency 0.00 12.00 12.00
Percent 0.00 26.67 26.67
Row Percent 0.00 100.00
Column Percent 0.00 31.58

Control

Frequency 6.00 15.00 21.00
Percent 13.33 33.33 46.67
Row Percent 28.57 71.43
Column Percent 85.71 39.47

Total 7.00 38.00 45.00
Percent 15.56 84.44 100.00

Chi-Square = 5.40 (DF = 2, p = 0.07)

Liklihood Ratio Chi-Square = 6.89 (DF = 2, p = 0.03)







a Chi-square test was conducted (see table 11). No significant differ-

ences were found among groups. Hypothesis 2 was therefore not rejected.

Hypothesis 3 There is no difference in Apgar scores in infants

born to mother's who complete either a hypnosis program, a suppor-

tive counseling program, or who receive no treatment.

Physiological functioning of the newborn infants was measured

through the use of Apgar scores at 1 and 5 minutes following birth. The

scores for all subjects infants ranged from 1-9 for Apgar 1, and 1-10

for Apgar 5. Tables 12 and 13 indicate the results of analyses of

variance run on these two measures among groups. Neither analysis

indicated significant differences in scores among the groups. Based

upon these results, hypothesis 3 was not rejected.

Hypothesis 4 There is no difference in the perceived length of

labor by mothers who complete either a hypnosis program, a suppor-

tive counseling program, or who receive no treatment.

Birth records were used to evaluate whether subjects in the various

groups perceived differing lengths of labor as measured in hours of

contractions prior to delivery. The range of hours of contractions

among all subjects varied from 0-40 hours. Table 14 shows the results

of an analysis of variance to determine whether the perceived lengths of

labor among subjects in the hypnosis, supportive counseling, and control

groups varied significantly. No significant differences were found.

Table 15 indicates the mean number of hours of perceived labor in

each of the groups. Based on the statistical findings, hypothesis 4 is

not rejected.




U/








Table 9

Mean Birthweights of Infants by Group (in Grams)


Sample Group: Hypnosis Supportive Counseling Control


Sample Size 12 12 21

Mean 3097 3250 2721















Analysis of Variance:


Source DF


Model 2

Error 42


Corrected Total 44

Source DF


GRP 2


Table 10

Infant Birthweights by Group


Sum of Squares Mean Square


2433130.16 1216565.08

21695047.62 516548.75


24128177.78

Type I SS F Value PR F


2433130.16 2.36 0.11












Table 11


Chi-Square:


Low Birthweight Measure b Group


Group (< 2500 ) ( 2500 ) Total


Hypnosis

Frequency 11.00 1.00 12.00
Percent 24.44 2.22 26.67
Row Percent 91.67 8.33
Column Percent 29.73 12.50


Supportive Counseling

Frequency 11.00 1.00 12.00
Percent 24.44 2.22 26.67
Row Percent 91.67 8.33
Column Percent 29.73 12.50

Control

Frequency 15.00 6.00 21.00
Percent 33.33 13.33 46.67
Row Percent 71.43 28.57
Column Percent 40.54 75.00

Total 37.00 8.00 45.00
Percent 82.22 17.78 100.00


Chi-Square = 3.14


(DF = 2, p = 0.21)


Likelihood Ratio Chi-Square = 3.23 (DF = 2, p = 0.20)













Table 12

Analysis of Variance: Apgar at One Minute Scores by Group


Source DF Sum of Squares Mean Square


Model 2 5.30 2.65

Error 42 251.91 6.00


Corrected Total 44 257.21

Source DF Type I SS F Value PR F


GRP 2 5.30 0.44 0.65












Table 13

Analysis of Variance: Apgar at Five Minutes Scores by Group


Source DF Sum of Squares Mean Square


Model 2 1.72 0.86

Error 42 95.39 2.27


Corrected Total 44 97.11

Source DF Type I SS F Value PR F


GRP 2 1.72 0.38 0.69







Hypothesis 5 There is no difference in the use of anesthetic/anal-

gesic drugs during the delivery of infants born to mothers who

complete either a hypnosis program, a supportive counseling pro-

gram, or who receive no treatment.

The type and amount of analgesic and anesthetic agents used during

the deliveries of all subjects were derived from their obstetrical

records. Amounts of chemical agents were found to be unrecorded in most

instances. Types of procedure or agents were categorized in an ordinal

scale ranging from no anesthetic (or local-pudendal for repair) during

labor to general anesthesia using a five point scale. Scores ranged

from 1-5 in the total population. Due to the limitations in the data, a

chi-square test was used to determine if differences among groups on

rates of no anesthesia during labor as opposed to anesthesia during

labor were present (Table 16). No significant differences were found

among groups. Therefore, hypothesis 5 was not rejected.
















Perceived


Source


Model

Error


Corrected Total

Source


GRP


Table 14

Analysis of Variance:
Hours of Contractions by Group


DF Sum of Squares


2 208.05

37 4803.56


39 5011.61

DF Type I SS F Valu4


2 208.05 0.8


Mean Square


104.02

129.83


PR F


0.46


e


~------




I It








Table 15

Mean Hours of Perceived Contractions by Group


Sample Group: Hypnosis Supportive Counseling Control


Sample Size 11.00 11.00 21.00

Mean 7.83 9.55 12.95












Table 16


Chi-Square:
Use vs. Non-use of Anesthetic Agents During


Delivery by Group


Anesthetic: Non-use Use Total


Group

Hypnosis

Frequency 8.00 4.00 12.00
Percent 17.78 8.89 26.67
Row Percent 66.67 33.33
Column Percent 30.77 21.05


Supportive Counseling

Frequency 6.00 6.00 12.00
Percent 13.33 13.33 26.67
Row Percent 50.00 50.00
Column Percent 23.07 31.58


Control

Frequency 12.00 9.00 12.00
Percent 26.67 20.00 46.66
Row Percent 46.15 47.37
Column Percent 57.14 42.86


Total 26.00 19.00 45.00
Percent 57.78 42.22 100.00


Chi-Square = 0.9 (DF = 2, p = .51)













CHAPTER V
SUMMARY, LIMITATIONS, DISCUSSION OF RESULTS, CONCLUSIONS,
IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER STUDY


Summary

The purpose of this study was to examine the effects of hypnosis

and supportive counseling on pregnant women identified as high-risk for

premature delivery. The identified variables assessed included

gestational age of newborns, birthweight, Apgar scores, length of labor,

and anesthetic and analgesic agents used during the delivery process. A

hypnosis treatment, a supportive counseling treatment and a no treatment

control condition were compared in terms of their effects on the various

pregnancy and delivery variables.

Significant differences in the length of gestation among groups

were found (Table 5) with subjects in the hypnosis and supportive coun-

seling treatments experiencing significant increases as opposed to the

control treatment (Table 6).

No significant differences in birthweight, Apgar scores, length of

labor, or use of anesthetic or analgesic agents were reported among

groups. These findings are reported in Table 8, Table 11, Table 12,

Table 13, and Table 15 respectively.


Limitations

While this research presents some support for the use of both

hypnosis and supportive counseling in the treatment of high risk for

premature delivery women, it mLst be considered pilot work in an area







that has gone largely unexplored in the last twenty years. Although

supportive counseling has been supported in earlier research by Mann

(1956, 1957), and Javert (1958) for the extension of preterm pregnan-

cies, hypnosis has been, at best, referred to as potentially offering

benefits in selected case studies. However, this investigation must be

viewed in light of a number of problems inherent in its design.

Initially, this research was planned to be run using groups of

women attending the Obstetric Clinic on the same day. This model would

allow for the benefits of group interaction, support and modeling.

However, it became apparent that the selected population of women were

inconsistent in making appointments, arrived significantly late for

appointments that were made, and at least initially, had minimal interest

in being responsive to the structure requested by the experimenter.

Thus, all subjects in the experimental conditions were treated indi-

vidually.

While this design became feasible, physical problems throughout the

treatment sessions reigned. Since subjects were seen during clinic

visits, space and uninterrupted blocks of time were often difficult or

impossible to obtain. A premium on office space meant that whatever

setting the experimenters could use (offices, examination rooms,

closets, etc.) was used. However, the space was also in need by others,

which meant frequent interruptions were often the case.

Feelings expressed by the majority of the hypnosis subjects

involved anger, fear, or frustration with the medical staff, typically

related to experiences in prior pregnancies. While the majority of

medical staff did not impede this research, neither were they in a

position to support it. The ambiguous relationship between the medical
I




/0


staff and hypnosis experimenters in a medical setting may well have been

confusing to the subjects.

Another source of contamination to the study may be in the suppor-

tive counseling leader's medical background and ongoing position in the

clinic setting. While hypnosis leaders limited their sessions to four

with subjects, some form of continued contact between the supportive

counseling leader and her subjects beyond four sessions was often

inevitable.


Discussion of Results

Women who participated in the hypnosis and supportive counseling

treatments displayed significantly longer pregnancies than the control

subjects (Table 5, Table 6). In the same directions, birthweights of

hypnosis and supportive counseling subjects tended toward being greater

than in the controls (Table 8, Table 9). While both experimental treat-

ments showed a similar outcome, the question arises as to whether the

same factors or different ones were instrumental in making these rather

limited interventions impactful. While the present research does not

allow for a definitive response to this question, it may be suggested

that different processes may have been involved in the two experimental

groups. The supportive counseling treatment was clearly directed toward

the conscious process, focusing on education, support, and alleviation

of overt fears, concerns and questions. The hypnosis treatment was less

clearly focused on these conscious issues, and more focused on the

unconscious process. The treatment attempted to offer the same com-

ponents of education and support through the unconscious mind of women.

The differences among groups may indicate that as Cavenaugh and Talisman







(1969) suggested, prematurity cannot be dealt with simply as a medical

problem, but must be attacked through a variety of avenues and

approaches.

While results did not show significant differences among popula-

tions for perceived lengths of labor (Table 13), a trend was noted among

groups (Table 14) with the mean labors being identified shortest by the

hypnosis subjects (7.38 hours), followed by the supportive counseling

subjects (9.55 hours), and the longest by the control subjects (12.95

hours). This tendency lends support to the hypothesis that hypnosis

subjects do perceive their labors as shorter than non-hypnosis subjects.

Werner's (1963) belief that this difference is simply a function of less

perceived discomfort in hypnosis clients during the early phase of

contractions may be plausible. The hypnosis subjects repeated mentions

of greater confidence and applicability of hypnosis in reducing discom-

fort (Appendix G) seems to support this belief. While the direct

measurement of the use of chemical anesthetic agents during the delivery

process among groups displayed no significant difference, the measure-

ment appears to have been confounded by a number of variables including

the inconsistent or limited reporting of it in patient's medical

records, the reduced need and medical advisability of using any chemcial

anesthetics involving deliveries of pre-term infants, the differing of

preferences in use of anesthetic agents by various medical staff, and

the limited control the clinic patient may be offered or assert during

the delivery process.

The two treatment approaches were undertaken to assess the impact

of psychological techniques on the woman at high risk of prematurity.

Both hypnosis and supportive counseling subjects appeared to benefit







from the approaches. Both approaches may have offered the following

benefits:

1) More attention: all women received four individual sessions

that focused primarily on their psychological needs.

2) Increased focus on the issues of being a woman at high-risk for

pre-term delivery: these women all received directed attention

concerning their condition.

3) The patient's role in her pregnancy: in both groups, an attempt

was made to convey to the subjects their role in the pregnancy

and the potential benefits to the fetus which they had power

over.

Perhaps the concept of the patient's power, control, and responsibility

was most clearly focused on through the hypnotic treatment program. The

concepts of the subject being a client, capable of decisions and control

over the process, were presented through both overt conscious messages

and also through unconscious suggestions. Statements by hypnosis sub-

jects (Appendix G) such as "feeling successful," "healthier," being

more in control of the discomfort, able to stop headaches, etc., doing

"a good job with the pregnancy," and believing or knowing they will

carry to term all support the belief that hypnosis offered these women a

sense of control and power over their pregnancies.

Hypnosis may have offered pregnant women a means to extend the

length of gestations that might have been dangerously short, as suppor-

ted by this research, as well as a concept and technique which may

benefit these mothers in their future pregnancies.







Conclusions

The following conclusions may be drawn from data presented in this

study:

1) Women at high risk of premature delivery who complete a hypnosis

or supportive counseling treatment program have longer gesta-

tions than those who receive no specialized psychological treat-

ment program.

2) There is no difference in the birthweights or Apgar Scores of

the children of women at high risk to deliver prematurely who

complete either a hypnosis treatment program, a supportive coun-

seling treatment program, or no specialized psychological treat-

ment program.

3) Women at high risk for preterm delivery do not differ signifi-

cantly in their perceptions of their lengths of labor, their use

of chemical anesthetics during delivery after receiving either

hypnosis treatment, or supportive counseling treatment, or no

specialized psychological treatment.


Implications

The following implications may be derived from data presented in

this study:

1) Although a short term program of hypnosis or supportive coun-

seling on women at high risk for preterm delivery may not

provide sufficient time for individuals to undergo changes in

all areas of the gestation and birth process, it may provide

sufficient impact to create changes in the area of length of

pregnancy as noted in Tables 5 and 6. The implication here for







counselors and the obstetric medical community is that a

relatively simple, time limited intervention of either suppor-

tive counseling or hypnosis can increase the probabilities of

high risk women having nearer term deliveries and thereby,

hopefully, healthier infants.

2) The fact that these treatment models were undertaken under

conditions less than optional (space problems, interruptions,

etc.) and yet were effective in creating change in length of

pregnancies implies that these treatments may merit considera-

tion even when time, space, consistency of appointments and

actual uninterrupted blocks of time are limited.

3) This study has implications for the relationship between

obstetrical patients and medical staff. Feedback from the

hypnosis subjects (Appendix G) indicates that while feelings

toward the medical staff are often hostile or fearful as a

result of previous interactions, these feeling appear to

diminish and be replaced by statements of control and self-

assuredness with treatment. It may be that, in order to opti-

mize the ongoing relationship between medical staff and

patients, psychological interventions such as hypnosis training

will benefit the patient by offering them an awareness of

control and responsibility which will reduce frictions, mis-

communications, frustrations and fear between them and medical

personnel.







Recommendations for Further Study

The following recommendations for further research are prompted by

issues arising from this investigation:

1) It is recommended that future investigations vary the length of

both experimental treatments (hypnosis and supportive coun-

seling) to ascertain whether this effects changes in the length

of gestation as well as birthweight, Apgar measures, perceived

hours of contractions and use of anesthesic in high risk for

preterm delivery women.

2) It is recommended that the hypnosis and supportive counseling

be offered as a single treatment intervention to high risk

mothers to determine if this impacts on pregnancy and delivery

variables.

3) It is recommended that future investigations use group

approaches to offer these same treatments to identify whether

pregnancy and delivery variables may be affected in high risk

mothers by a different treatment delivery model.

4) Since the present research used a videotape presentation of a

group hypnotic induction and education package, it is recommen-

ded that further studies look at the benefits of completely

videotaped hypnosis training packages being used with high risk

mothers.

5) It is recommended that private (as opposed to clinic) patients

at high risk for preterm delivery be offered treatment programs

to determine their effect on pregnancy and delivery measures.

6) The training of obstetricians in the use of hypnotic and

supportive counseling approaches is recommended. It is







recommended that high risk patients of these physicians be

offered the treatment programs either directly or under the

auspices and encouragement of these physicians.

7) The potential benefits of earlier training and use of hypnotic

procedures are recommended for high risk mothers with the goal

to measure the benefits in follow up studies focusing on later

pregnancies, family harmony, mother's general health and

psychological intervention and prevention techniques in future

research.

8) The application of psychological treatment programs (specific-

ally hypnosis) and furthered research on these techniques are

recommended not only in the area of obstetric medicine, but for

any area of medicine where the patients may benefit from a

heightened sense of control, psychological well-being, aware-

ness of their psychological assets, and becoming a more active

member of their own physical health program.













APPENDICES


















a)

4-













V)
4-
C









0











0




CS-
Co







a )

0 U



















0
Sa)
(U-b



















U,










O
.C C

0


C( VI


I 1
C\J S-





Ln S-
ia
0.
.0 0 .C $-
.- a)

































-0-
U S
C 0) C -



a) S-

























0 3
0 C








0 0

Ca)C

.C4-> >>



o U Q)
































O--
S->



C\J









CD



<0 C

Sf0 U'
^= Q
s- tL
01 0)J
0) C -
LC 0
3 aO

> o n


0)
U, -s
-14
au C (

3 4- (n
0 a)
cJ -0C:
U) <


Ca)
O )-
(CU







(0)


O-I

0 0.


LC
0



+4 ., *
4- -.0





aC U a



S- 3 1

a) Cm 4-. )
E a) =


*0

0






a)
U
) C
0





a)O
-0 S
a 3
U 0


O

CU
a)
S..
0. V
0

'U 10

U 0

0C
<0 *


'u
4V)
a)

U,
'U





ui

>-

CO






CD
0U
e0

wO






0-








LL
0
CD
LU)
















LUi
Qx
au
a:
oo




LU
OC
<_


S-

0)




0e












,
C



















O







L
3.0
S->
() +'U
S-














0E
ao)
S-a)
Q. VI


E

11

U,
II




LO












aV
E


C














4-.
0. C



*4-




0
a)U,
a)
E n


OO
C4-
a
U,

a
a)
or

C











a. C




S-
uo





VO)
U a


O E
C U0
O C
0 O

o -- -a
O 4-

o CC
V) .C.C

2a
3c
0 S- S-
4 -4) 4)
>+ S- -=
s- (u 0 (0
a) +-) .= C.-
> U) (A -













APPENDIX B
INFORMED CONSENT FORM


Protocol #


PROJECT TITLE:


The extension of Pregnancy through the Application of
Counseling and Focused Relaxation with Mothers at Risk
for Premature Delivery.


PATIENT'S NAME:


HOSP #


DATE


The following information has been explained to me by
pertaining to the care I will re-
ceive during the last three months of my prenatal care at Shands
Teaching Hospital.

Some pregnant women go into labor early and deliver a premature infant.
Because the baby comes early it is more likely to have problems during
labor and after delivery. Today there is no clear explanation as to why
some women deliver prematurely.

You have been identified by our Obstetric staff as possibly being at
risk for a premature delivery.


So that we can be certain of how far
examination called ultrasound. This
view the way your baby is positioned
mine the baby's age by measuring the
the leg. The test does not cause any
associated with known harmful effects


pregnant you are we will do an
examination utilizes sound waves to
in your womb and also help deter-
baby's head and the long bones in
discomfort and to date is not
on you or your baby.


During the last three months of your pregnancy you will be asked to join
a group of other women for discussions, counseling, focused relaxation
or both counseling and focused relaxation. You will be assigned to a
group by random. The sessions will be conducted by staff from the
Psychology Department and will coincide with your scheduled prenatal
visits.

Counseling Group: There will be four groups sessions that will be
supportive and offer you the opportunities to discuss your concerns
surrounding pregnancy and delivery, the addition of a newborn in your
life, and the benefits of carrying this baby to term for you and your
baby.

Focused Relaxation Group: There will be four sessions offered focusing
on opportunities to experience and learn the methods and benefits of




VJ.J


focused relaxation. Focused relaxation has been shown to effectively
deal with the anxiety, fears and pain associated with pregnancy and the
birth experience.

There are no known risks to these procedures. The only discomfort is
with the added length of time spent in the clinic area. Potential
benefit will be prevention of the baby being delivered early. Another
alternative to this is bed rest at home. There will be no compensation
for your participation in this study.

You are free to withdraw your consent at any time as the study proceeds.
Refusal to allow the participation of yourself or your baby in these
studies will not prejudice the medical care you will receive nor affect
your future relationships with the University of Florida.

It is agreed that the information gained from these investigations may
be used for educational purposes which may include publication. It
shall be understood that all data will be maintained confidentially and
no publication will identify me or my baby by name.

In the event of myself or my baby sustaining a physical injury which is
proximately caused by this experiment, professional medical care re-
ceived at the J. Hillis Miller Health Center exclusive of hospital
expenses will be provided without charge.

I have read and understand the above described procedure in which I am
to participate and have received a copy of this information.




(WITNESS) (SIGNED)

I have fully explained to the nature and
purpose of the above described procedure and the risks that are involved
in its performance. I have answered and will answer all questions to
the best of my ability.













APPENDIX C
HYPNOSIS GROUP PROTOCOL

SESSION I

"Good morning! I know that you are pregnant and are hoping for a

comfortable, pleasant, healthy pregnancy and delivery. What you will be

doing in this program in the next few visits will be of benefit to you

as well as to your child. You have been selected from a larger group of

patients to participate in a project designed to increase the likelihood

of happy, healthy pregnancies and deliveries.

The skills you can learn in this program offer you a way of

learning how to relax, be comfortable, and more fully enjoy your preg-

*nancy.

What you can learn is called focused relaxation. Focused relax-

ation refers to: a structural method of learning to relax and control

bodily tensions. Clinical work using these techniques in obstetrics

over the last few years have shown that mothers who learned these tech-

niques can look forward to a reduction in fear, tension, and pain before

and during the delivery; a speedier recovery following delivery; less

fatigue and thus less maternal exhaustion; more control during the

pregnancy and delivery; more awareness and enjoyment of the experience

of childbirth and fewer side effects due to the drugs following the

delivery.

I'd now like to put on a videotape which will explain the process

to you as well as show some women who are actually learning this method







of relaxation. Afterward, you will have an opportunity to begin to

learn and enjoy these techniques."

(Tape begins) Introduction to Focused Relaxation

"At the present time, I hope I'm awake. If I am, then if that door

over there opens up, my head will immediately turn in that direction to

see who is coming in the door. If I'm in a state of focused relaxation

when this happens, I will know distinctly that the door has just opened

and somebody is coming into this room, but I'm so comfortable, so com-

pletely relaxed that it just doesn't bother me at all. I wouldn't under

any circumstances open up my eyes. I'm just too comfortable to do

anything like that. This is basically the feeling you get in the state

of focused relaxation -- a feeling of comfort and relaxation. When you

learn how to do this, you are learning how to use another mind that you

have. Normally when you are awake, you are using your conscious mind.

When you learn how to go into focused relaxation, you are using your

unconscious mind, as we like to call it. And it so happens that your

unconscious mind is a much more suggestable mind than your conscious

mind. So that suggestions given to you while you are in the focused

relaxation state are much more likely to be accepted if they have some

value, your unconscious mind is not a gullible mind. It will never

accept a suggestion, unless you feel it will be of value to you. In

fact, if we gave you a suggestion of any harm to yourself, you would

come right out of the focused relaxation state, and instead of doing

what you were told to do, you'd go right out the door and leave and

probably never speak to me again. So you don't have to be concerned.

You can only enter the state of focused relaxation when you desire to do

so, because you must learn how to go into focused relaxation.







Now I stress the word learn how to do it, because focused relax-

ation is purely a skill that is learned. I'm supposed to be here as a

teacher trying to teach you to learn to enter focused relaxation, and

how do you learn anything -- by following instructions! You buy some

piece of material or piece of equipment at a place. It comes in all

sorts of different parts. You won't get it together unless you follow

the instructions. That's the same method in focused relaxation. Follow

the instructions and you will end up in a state of focused relaxation.

Now, how do you follow instructions? Well, you simply do what you are

asked to do.

What we know is that virtually everyone can learn to enjoy focused

relaxation. What's very nice about this method of learning is that the

more comfortable you become, the more fully you can appreciate and learn

focused relaxation. All you need to do is listen to me and allow

yourself to experience this very pleasant state. Like anything you

learn, the more often you do it the better you will be.

Focused relaxation is a way of helping you to allow yourself to

become comfortable and relaxed while still being awake. It's something

like when you're watching an especially good show on TV, or reading an

especially good book -- you may be concentrating quite a bit, but it's

not tiring, instead it feels good.

Now, in a few moments, all of you, if you desire, will be in this

particular state called the focused relaxation state -- the state of

comfort and relaxation. I'm sure you are going to enjoy learning how to

get into this state. I think you can enjoy the fact that you will learn

what it feels like to be in this state, because what we're teaching

really is one thing relaxation. If we could teach the whole world how







to relax, what a wonderful world this would be. So be prepared to

experience some very wonderful, pleasant feelings in just a few

moments."


A TAPED INDUCTION

"You have to be comfortable to do this, so will each of you sit on

the chair with your arms sort of resting on the side bars. Get yourself

nice and comfortable. If you have anything on that's too tight, loosen

it up. Just feel nice and comfortable and relaxed so you can do this.

We like to use what is called an eye fixation technique. We ask

all of you to look at the ceiling. We're lucky because we have a bunch

of spots up there. Just pick one that looks particularly attractive to

you and keep your eyes glued to the spot. That's it, try not to take

your eyes off it for even a split second. As you sit there staring at

this spot just being as calm and motionless as you possibly can, I'd

like you to notice several things. Now the first thing to notice is a

change that takes place in your breathing. From way over here, I can

see that the change has already taken place for each one of you. Right

now you are breathing a bit more slowly, a bit more deeply than you

ordinarily do when you are wide awake, and this approaches the slow,

deep breathing of night-time sleep. As you continue to stare at the

spot with this slow, deep, sleepy type of breathing, notice that your

eyes have gotten tired, that the lids are heavy. You may blink them

from time to time. That's alright. That's a good sign. It's a sign

that they have gotten tired, that they are heavy. That's fine. Now

very shortly, your eyes will be so tired, the lids will be so heavy that

you will permit them to close, shut tight; and just as soon as you do,