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

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

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Subjects / Keywords:
Childbirth ( jstor )
Hypnosis ( jstor )
Hypnotics ( jstor )
Infants ( jstor )
Mothers ( jstor )
Obstetrics ( jstor )
Pregnancy ( jstor )
Psychological counseling ( jstor )
Psychological stress ( jstor )
Women ( jstor )
Hypnotism in obstetrics ( lcsh )
Premature infants ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

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

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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ACN9032 ( NOTIS )
11698206 ( OCLC )
AA00004894_00001 ( sobekcm )

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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




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 Biel 1ing 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.
ii i


TABLE OF CONTENTS
ACKNOWLEDGEMENTS
LIST OF TABLES vi
ABSTRACT vi i
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
v


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
I
VI


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 Shards Obstetric Clinic in Gainesville, Florida, and had
been identified as "high risk" for premature delivery. Their ages
ranged frcm 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
vi i


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.
vi ii


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).
1


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 suprising, then, is that the use of
psychological intervention during pregnancy of high risk mothers has
been empirically supported (Blau et al., 1963; Cavenaugh & Talisman,


3
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 progessionals, 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).


5
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.
I


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;


7
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


10
"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.
11


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


13
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, multpara 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.,


15
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 womens' 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.


IO
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, primparas, 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
1


(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 (diastolic 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,


C-\J
mortgage or loan less than $10,000, forclosure 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
1iterature.
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 plesant 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 timeand 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 experimentations 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 suprisingly 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 concensus 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 severly unpleasant reaction which would


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 suprising 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


2b
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.


1
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


29
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


30
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


sJ I
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


32
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;
"L1accouchement 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
practicesrelaxation 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 analgesicstwilight sleep or
general anesthetic). However, looking once more at Davidson's (1962)
study comparing autohypnosis patients and physiotherapy-control led-


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 19501s 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).
Control of painful uterine contractions.
3.


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 physiotherapycontrol led 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


>3/
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.
I


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 forcep 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.


40
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 primparas 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-control led 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


+ I
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


research is
assistance
an attempt to offer the expectant mother psychological
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.
43


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.


47
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.


U I
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
plansboth immediate and into the future.
6. To offer appropiate feedback, support and advice concerning any
or all of the aformentioned 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
I


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.


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 £
< .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
54


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.


bb
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


¡3/
Table 2
Descriptive Statistics for Parity
Sample Group:
Hypnosis
Supportive Counseling
Control
Term Deliveries
Mean
.83
oo
CO
.76
Minimum
0.0
o
0
o
0.0
Maximum
2.0
2.0
4.0
Premature Deliveries
Mean
.66
CO
LO
0
.76
Minimum
0.0
o
0
o
O
0
o
Maximum
2.0
1.0
3.0
Abortions
Mean
1.1
1.4
.85
Minimum
O

o
o
0
o
O
0
o
Maximum
6.0
3.0
3.0
Living Children
Mean
.9
.8
1.15
Minimum
o

O
0.0
0.0
Maximum
2.0
2.0
4.0


S-/VJ
Table 3
Analysis of
Variance:
Cruz
High Risk of Preterm
by Group
Delivery Scale
Source
DF
Sum of Squares
Mean Square
Model
2
19.72
9.86
Error
41
118.72
2.90
Corrected
Total
43
138.44
Source
DF
Type I SS F
Value PR F^
GRP
2
19.72
3.40 .04


oy
Table 4
Analysis of Variance: 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


bU
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


0
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
A
39.33
12
Supportive Couns.
B
B
A
38.42
12
Hypnosis
B
36.10
21
Control


b4
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 counsel in 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,
I


65
Table 8
Chi-Square: Preterm vs. Term Pregnancy Measurement by Group
Group
.Preterm Term Total
(< 36 wks.) (^36 wks.)
Hypnosis
Frequency
Percent
Row Percent
Column Percent
1.00
2.22
8.33
14.29
11.00
24.44
91.67
28.95
12.00
26.67
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
Percent
Row Percent
Column Percent
6.00
13.33
28.57
85.71
15.00
33.33
71.43
39.47
21.00
46.67
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)


VJU
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


DO
Table 10
Analysis of Variance: Infant Birthweights by Group
Source
DF
Sum of Squares
Mean Square
Model
2
2433130.16
1216565.08
Error
42
21695047.62
516548.75
Corrected Total
44
24128177.78
Source
DF
Type I SS F
Value
PR F
GRP
2
2433130.16
2.36
0.11


\J J
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)


/ \J
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.


/ o
Table 14
Analysis of Variance:
Perceived Hours of Contractions by Group
Source
DF
Sum of Squares
Mean Square
Model
2
208.05
104.02
Error
37
4803.56
129.83
Corrected Total
39
5011.61
Source
DF
Type I SS F
Value
PR F
GRP
2
208.05
00

o
0.46


/ *T
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
Percent
Row Percent
Column Percent
8.00
17.78
66.67
30.77
4.00
8.89
33.33
21.05
12.00
26.67
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 mist be considered pilot work in an area
76


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 initally, had minimal interest
in being responsive to the structure requested by the experimenter.
Thus, all subjects in the experimental conditions were treated indi
vidual ly.
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


staff and hypnosis experimentors 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
treatmeants 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 applicaton 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
85


APPENDIX A
CREASY'S RISK OF PRETERM DELIVERY SCORING SYSTEM (Creasy et al., 1980)
NAME: HOSPITAL NUMBER:
RISK OF PRETERM DELIVERY
Points Points
Socioeconomic Status
Past History
Daily Habits
Current Pregnancy
1
2 children at home, low
socioeconomic status
1 abortion; less than
1 year since last birth
work outside
home
unusual fatigue
2
younger than 20 years
older than 40 years
single parent
2 abortions
more than 10
cigarettes
per day
13 kg gain by 32
weeks gestation
albuminuria, hyper
tension, acteriuria
3
very low socioeconomic
status
shorter than 150 cm
lighter than 45 kg
3 abortions
heavy work
long tiring
trip
breech at 32 weeks
weight loss of 2 kg
head engaged
febrile illness
4
younger than 18 years
pyelonephritis
metrorrhagia after
12 weeks gestation
effacement; dilatation
uterine irritability
5
uterine anomaly; second-
trimester abortion
DES exposure
placenta previa
hydramnios
10
premature delivery; repeated
second trimester abortion
twins
abdominal surgery
*$core is computed by addition of the number of points at any given time. 0-5 = low risk; 6-9 = medium risk
Date of scoring: Weeks of gestation -10 = high risk


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 wi 11 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 pregnant you are we will do an
examination called ultrasound. This examination utilizes sound waves to
view the way your baby is positioned in your womb and also help deter
mine the baby's age by measuring the baby's head and the long bones in
the leg. The test does not cause any discomfort and to date is not
associated with known harmful effects 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
87


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. Hi 11 is 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
89


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.


91
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


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 Biel 1ing 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.
ii i

TABLE OF CONTENTS
ACKNOWLEDGEMENTS Ü
LIST OF TABLES vi
ABSTRACT vi i
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
v

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
I
VI

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 Shards Obstetric Clinic in Gainesville, Florida, and had
been identified as "high risk" for premature delivery. Their ages
ranged frcm 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
vi i

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.
vi ii

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).
1

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 suprising, then, is that the use of
psychological intervention during pregnancy of high risk mothers has
been empirically supported (Blau et al., 1963; Cavenaugh & Talisman,

3
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 progessionals, 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).

5
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.
I

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;

7
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

10
"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.
11

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

13
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, multípara 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.,

15
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 womens' 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.

IO
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, primíparas, 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
1

(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 (diastolic 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,

C-\J
mortgage or loan less than $10,000, forclosure 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
1iterature.
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 plesant 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 experimentations 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 suprisingly 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 concensus 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 severly unpleasant reaction which would

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 suprising 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

2b
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.

¿1
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

29
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

30
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

sJ I
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

32
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;
"L1accouchement 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-control led-

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).
Control of painful uterine contractions.
3.

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—control led 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

>3/
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.
I

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 forcep 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.

40
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 primíparas 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-control led 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

*fr I
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

research is
assistance
an attempt to offer the expectant mother psychological
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.
43

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.

47
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.

U I
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 appropiate feedback, support and advice concerning any
or all of the aformentioned 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
I

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.

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 £
< .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
54

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.

bb
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

¡3/
Table 2
Descriptive Statistics for Parity
Sample Group:
Hypnosis
Supportive Counseling
Control
Term Deliveries
Mean
.83
oo
CO
.76
Minimum
0.0
o
•
o
0.0
Maximum
2.0
2.0
4.0
Premature Deliveries
Mean
.66
00
LO
•
.76
Minimum
0.0
o
•
o
O
•
o
Maximum
2.0
1.0
3.0
Abortions
Mean
1.1
1.4
.85
Minimum
O
•
o
o
•
o
O
•
o
Maximum
6.0
3.0
3.0
Living Children
Mean
.9
.8
1.15
Minimum
o
•
O
0.0
0.0
Maximum
2.0
2.0
4.0

S-/VJ
Table 3
Analysis of
Variance:
Cruz
High Risk of Preterm
by Group
Delivery Scale
Source
DF
Sum of Squares
Mean Square
Model
2
19.72
9.86
Error
41
118.72
2.90
Corrected
Total
43
138.44
Source
DF
Type I SS F
Value PR F^
GRP
2
19.72
3.40 .04

oy
Table 4
Analysis of Variance: 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

bU
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

0¿
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
A
39.33
12
Supportive Couns.
B
B
A
38.42
12
Hypnosis
B
36.10
21
Control

b4
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 counsel in 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,
I

65
Table 8
Chi-Square: Preterm vs. Term Pregnancy Measurement by Group
Group
.Preterm Term Total
(< 36 wks.) (^36 wks.)
Hypnosis
Frequency
Percent
Row Percent
Column Percent
1.00
2.22
8.33
14.29
11.00
24.44
91.67
28.95
12.00
26.67
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
Percent
Row Percent
Column Percent
6.00
13.33
28.57
85.71
15.00
33.33
71.43
39.47
21.00
46.67
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)

VJU
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

DO
Table 10
Analysis of Variance: Infant Birthweights by Group
Source
DF
Sum of Squares
Mean Square
Model
2
2433130.16
1216565.08
Error
42
21695047.62
516548.75
Corrected Total
44
24128177.78
Source
DF
Type I SS F
Value
PR F
GRP
2
2433130.16
2.36
0.11

\J J
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, £ = 0.21)
Likelihood Ratio Chi-Square = 3.23 (DF = 2, p = 0.20)

/ \J
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.

/ u
Table 14
Analysis of Variance:
Perceived Hours of Contractions by Group
Source
DF
Sum of Squares
Mean Square
Model
2
208.05
104.02
Error
37
4803.56
129.83
Corrected Total
39
5011.61
Source
DF
Type I SS F
Value
PR F
GRP
2
208.05
00
•
o
0.46

/ *T
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
Percent
Row Percent
Column Percent
8.00
17.78
66.67
30.77
4.00
8.89
33.33
21.05
12.00
26.67
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 mist be considered pilot work in an area
76

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 initally, had minimal interest
in being responsive to the structure requested by the experimenter.
Thus, all subjects in the experimental conditions were treated indi¬
vidual ly.
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

staff and hypnosis experimentors 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
treatmeants 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 applicaton 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
85

APPENDIX A
CREASY'S RISK OF PRETERM DELIVERY SCORING SYSTEM (Creasy et al., 1980)
NAME: HOSPITAL NUMBER:
RISK OF PRETERM DELIVERY
Points Points
Socioeconomic Status
Past History
Daily Habits
Current Pregnancy
1
2 children at home, low
socioeconomic status
1 abortion; less than
1 year since last birth
work outside
home
unusual fatigue
2
younger than 20 years
older than 40 years
single parent
2 abortions
more than 10
cigarettes
per day
13 kg gain by 32
weeks gestation
albuminuria, hyper¬
tension, acteriuria
3
very low socioeconomic
status
shorter than 150 cm
lighter than 45 kg
3 abortions
heavy work
long tiring
trip
breech at 32 weeks
weight loss of 2 kg
head engaged
febrile illness
4
younger than 18 years
pyelonephritis
metrorrhagia after
12 weeks gestation
effacement; dilatation
uterine irritability
5
uterine anomaly; second-
trimester abortion
DES exposure
placenta previa
hydramnios
10
premature delivery; repeated
second trimester abortion
twins
abdominal surgery
*$core is computed by addition of the number of points at any given time. 0-5 = low risk; 6-9 = medium risk
Date of scoring: Weeks of gestation -10 = high risk

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 wi 11 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 pregnant you are we will do an
examination called ultrasound. This examination utilizes sound waves to
view the way your baby is positioned in your womb and also help deter¬
mine the baby's age by measuring the baby's head and the long bones in
the leg. The test does not cause any discomfort and to date is not
associated with known harmful effects 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
87

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. Hi 11 is 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
89

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.

91
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,

you'll feel so comfortable, so deeply relaxed that you'll permit them to
remain closed, shut tight until once again I suggest that you open them.
Go deeper and deeper and deeper relaxed, deeper and deeper and deeper to
sleep. Begin to feel, if you will, some very pleasant, heavy sensations
starting to come all over your body. Most of our subjects tell us they
start down in the feet, the soles of the feet, and you can feel a
pleasant heaviness developing down in the soles of your feet. It's a
sort of feeling that your feet are starting to fall asleep. Feel this
pleasant happiness work its way up through your feet going upward slowly
toward your ankles and then up into the lower part of your legs, par¬
ticularly the calf muscles, as you relax, deeper and deeper and deeper.
And then slowly feel these same pleasant sensations come up through your
knees and on up into your thighs, comfortable, relaxing sensations,
moving slowly upward through your thighs until they get all up into your
hips. And now notice that your legs do feel rather heavy, with a
pleasant heaviness, very comfortable heaviness and then you're deeply,
deeply, deeply relaxed. Notice the same sensations are already present
in your fingers, moving their way slowly up through your hands, on past
the wrist and into the forearms; pleasant, heavy comfortable, relaxing
sensations. Moving slowly up past your elbows and on into your upper
arms as you go deeper, and deeper and deeper to sleep. Slowly upward,
feel the pleasant heavy sensations moving all up to your shoulders and
now notice your arms, too, feel heavy with a very pleasant heaviness, a
very comfortable heaviness and that you are deeply, deeply, deeply
relaxed. Then the same sensations take told of your trunk, of your
torso. Feel them starting down in your hips and buttocks, this time,
and working their way upward two ways at once. Notice them coming up

-/"T
your back through the muscles along side your spine, then coming up the
front through the muscles of your abdomen. And then slowly upward,
front and back, into the muscles of your chest: pleasant, heavy, com¬
fortable, relaxing sensations, moving slowly upward all into the muscles
of your neck. Now notice that your whole body feels heavy, with a
pleasant heaviness, a very comfortable heaviness and that now you are
deeply relaxed. With your permission, because anything I do must be
with your permission, I'd like to teach you to go into still deeper
relaxation. I'm going to count from 1 to 20. I want you to notice how
each count takes you deeper, ...1,...2,...3, start to go deeper...4, 5,
much deeper a 1/4 asleep, 6, 7, 8, deeper, deeper, deeper, 9, 10, very
much deeper 1/2 asleep...11, 12, 13, into real deep relaxation...14, 15,
deeper than that 3/4 asleep...16, 17, 18, deeper, deeper, deeper, 19,
20, deeply and comfortably relaxed now, just comfort and relaxation.
You know this type of feeling. One day you came home dog tired and
threw yourself across a comfortable bed and you lay there with your eyes
closed. You weren't asleep. You could hear the television blaring in
the next room. But didn't it feel good, to be so pleasantly comfor¬
table, so deeply relaxed, feeling so well relaxed, feeling very, very
well. Each one of you are pregnant and expect to deliver a baby, and
it's a wonderful thing to be able to bring a new life into this world.
You should feel very proud of the fact that you are pregnant and going
to bring a baby into this world. And, of course, you want to do it in
the best possible way; you want to do it with the least danger or harm
to your baby or yourself. At the same time, you want to be comfortable.

95
(INDUCTION CONTINUES - EDUCATION OF WOMEN)
ON ISSUES OF PREGNANCY, DELIVERY &
MEDICAL PROCEDURES
"In the last forty or fifty years in this country, doctors have
been finding out that the patients who were educated about the mechanics
of childbirth are really doing the best jobs of delivering their babies,
that a lot of the fears that they had can be relieved when they know the
exact mechanics. Some of them are using natural childbirth, some are
using Lamaze, and similar techniques. Many of us have found out that
through focused relaxation these things can be augmented and made better
and so today I want you to realize that right now, your baby is living
and growing inside you in a large, muscular pear-shaped organ that we
call the uterus or womb. The walls of this organ are home for the baby,
being made up completely of muscular tissue. There has got to be an
opening some where in that organ or the baby couldn't get out. Such an
opening does exist, and it's down in the bottom of the uterus or womb.
That's at the bottom if you were in an upright position. It does stay
closed throughout your pregnancy so that your baby can live and grow
inside you. In order for your baby to be born, that organ must be
opened up; there must be some motive power to do this; that motive power
is generated by the muscles in the walls of the uterus or womb. They
will contract; they will get hard. Each time the muscles in the walls
of your uterus or womb contract and get hard, it will be doing something
for you. It will be opening up that cervix, the mouth of the womb,
until it finally dilates completely. And when it dilates completely,
there will be an opening between the uterus and the vagina, that cavity
in the lower part of your body through which you became pregnant.

Finally, after the cervix has dilated completely, the baby will start
its descent down through the uterus, out of the cervix, down through the
vagina and then out through the external vaginal opening, and the baby
will be born. So a series of contractions of the muscles in the walls
of the uterus will dilate the cervix, the mouth of the womb, until it
dilates completely. Now these contractions are not strange to you
because you've had muscular contractions all your life. Every time a
part of your body has moved, its taken either one muscle or a group of
muscles to move that particular part of your body. Every time you take
a breath, several groups of muscles are necessary to contract in order
for that to happen. Every time your heart beats, that's a muscular
contraction. So you know instinctively, muscles have been contracting
for you all your lives, while you've been completely comfortable. So
during your labor and delivery, the muscles in the walls of the uterus
can likewise contract while you're completely comfortable in order to
dilate the cervix, the mouth of the womb, until it dilates sufficiently
to let the baby start coming down through the birth canal, so it can be
born. Now about these muscular contractions and how they actually do
feel; we can do a little bit of testing right here and now in this
respect. In just a few moments, I'm going to ask you to take your
fingertips of your right hand and bring them up to your right shoulder.
As you do that, you'll be contracting the large muscle in the front of
your upper arm, the muscle called the biceps muscle. When you do that,
I'm going to ask you to take your left hand and bring it over to feel
that muscle and to feel how hard its become, because that's a pretty
violent musclar contractions. The muscles in the walls of the uterus
won't have to contract any more violently than that one. In fact, it

y/
will probably be even less. So now, if all of you will just take your
fingers, the fingertips of your right hand and bring them up to your
shoulder and let them rest on your right shoulder, then take your left
arm and put the fingers of your left hand on that big muscle in the
front of the upper part of your upper arm. Now feel that muscle there
and you can even make it harder, you can make it contract by pulling on
the arm closing the elbow so to speak and make it real firm and hard.
Feel how hard that muscle can get; that's a muscular contraction. I'm
sure you noticed that it doesn't hurt, doesn't bother you doing it. So,
the muscles in the walls of your uterus can contract in the same way.
Now, you can take the fingers of your left hand with your left hand and
arm and put them back on the arm of the chair where they were before and
you can take the fingers away from your right shoulder, and let your
right arm once again rest on the arm of the chair and go back into the
deepest relaxation that you can attain, go deeper, and deeper and deeper
relaxed, deeper, and deeper, and deeper relaxed. Now at the end of the
first stsge of labor, the muscles in the walls of the uterus aren't
going to quit, they're going to keep on contracting, but now for a brand
new purpose. Now they've got to get the baby out, so they'll keep on
contracting and push the baby down through the dilated cervix, through
the vagina and out through the vaginal opening, so it can be born.
However, you will be able to use the other muscles at the time to help
the uterus out. These are the muscles of your abdominal wall and the
muscles of your perinium, the perinium being the area down around the
rectum and the vagina. We won't have to teach you how to do this, your
unconscious mind, which is working for you in the state of focused
relaxation, knows exactly how you are supposed to use these muscles; and
I

it can teach you much better than I can. So that when you do go into
labor and dilate that cervix completely, your unconscious mind will come
right in to do its job and help you use those muscles of the abdomen and
muscles of the perinium to expelí your baby to get it out. Then
shortly, before that happens, as the baby's head or whatever part is
coming down first presents at the vaginal opening, it may become neces¬
sary in your obstetrician's judgement to help out a little bit to this
extent. He may notice that the opening of the vagina seems a little bit
small, and it will be sort of a tight fit to get that baby's presenting
part out. He may decide to make a small incision, which we call an
episiotomy to your perinium from the vagina, the back of the vagina down
toward the rectum. But do you know a strange thing, when he makes that
incision, it's not going to bother you. I'll tell you why. If you take
human tissue, you can practice this at home any time you want to. Take
any part of your body where there is a little bit of loose, flabby skin,
and pull that skin for a while so it stretches out and then test it to
see what it's become -- numb. The more you put human tissue like that
on the stretch, the more numb it becomes. So that by the time the
incision is made, that tissue's been put on the stretch, it's already
become numb, so that when the incision is made, rather than getting a
feeling of discomfort from it, you'll have a feeling akin to relief.
Relief to this extent, now you'll know, ooh there's plenty of room for
the baby to come through now; and so it will be a comforting feeling for
you to know that at that particular time. Then, of course, the baby
will be born. It might be necessary just before the baby comes out as
well to use a pair of what we call forceps. They are a pair of small
tools that interlock, which are smooth and which we can slide over the

99
baby's head so that if there is a rather tight fit higher up in the
vagina with a couple of bony provinces, these forceps can be used with
each contraction as you push and as you bear down, using the muscles of
the uterus, the muscles of your abdominal wall, and the muscles of your
perinium. At that particular time, a little traction can be made with
these forceps, as they grab the baby's head to pull it down a little bit
farther each time, to help you, so that the baby can come out more
easily. Then the baby is born, and just because the baby is born the
delivery isn't over. The cord between you and the baby will be cut and
tied; you won't even know that's happening. You won't feel anything
there whatsoever. Then it will be necessary to complete your delivery
with a third stage of labor, shortly after the baby is born and the cord
has been cut and tied, the baby has been put possibly right across your
abdomen for you to hold. That is the best place for the baby to go
after it has been born, and it's mouth has been suctioned clean and it's
nostrils have been suctioned clean, to put it there and that's where it
probably will be put if you so desire. But just at that time the
muscles of your uterus will again begin to contract; this time with a
third thing to do -- expelí the afterbirth, which is really called the
placenta. So a few contractions and usually it will all happen spon¬
taneously all by itself. Occasionally, it will be necessary to put a
hand on your abdomen to grasp the uterus between, in the palm of your
hand between the thumb and forefinger, which the doctor will do for you
of course, and gently exert some pressure on the uterus at that point to
give the placenta a little push downward to get it started. But that
doesn't happen all the time, just occasionally, and it won't bother you
at all because you will be completely relaxed; you'll have no discom-

1UU
fort. Once the placenta has been delivered, if an episiotomy has been
done or if by any chance a small tear has occurred somewhere in the wall
of the vagina, that will be repaired at that time. Notice, up to this
time, you haven't needed any anesthetic agent or anything and you may
want a little bit of novacaine put in at that time. We can do it,
there's no harm in it whatsoever; you've done your job. You've de¬
livered the baby now; so you might say to your obstetrician, 'Well, why
don't you do some work for a change, put a little novacaine in there
before you sew it up.' But, most of you won't even need that, because
the tissues will still be sufficiently numb, or you can be put into a
state where you will have numbness by simply being taken out of the
situation you're in...going somewhere else mentally or by dividing your
body into two halves, which I'll show you how to do later and keeping
the lower half sleeping while the upper half remains awake. Then that
way, you'll find out that you'll have plenty of numbness to have these
few little sutures in and then the whole thing will be complete.
While the obstetrician is sewing up the perinium, he will probably
talk to you something like this: 'Now, in these next few days, you're
going to have a very, very pleasant time here at the hospital. You'll
pass your water without being catherized; you'll move your bowels with¬
out enemas; you'll have a good appetite, you'll have no nausea and
vomiting after the operation; you'll be able to keep all the food down;
the food will be very pleasing to you; the nursing care at the hospital
will be very pleasing to you. Doubt if you might have a few sutures;
but if you do you know you'll hardly know they are there; they won't
bother you at all. In fact, you'll treat this whole period as a very,

very pleasant vacation.1 Now, relax deeply, and become more and more
deeply relaxed."
Brief Exposure to Imagery Sequence
"All of these pleasant things that we like to do must come to an
end sometime. So slowly, gradually, let this particular thing that
you're doing come to an end and return to the room that we started all
this in. You're sitting comfortably relaxed in the arm chairs staying
deeply, deeply, deeply asleep. Now in a few moments, I'm going to ask
each one of you to rouse up in this pleasant state.
When you return to this room you can bring back those feelings of
deep relaxation and comfort, and feel refreshed and awake. I'm now
going to count from 1 to 5, and when I reach 5 you can be back in this
room, awake, feeling refreshed and relaxed. 1...coming...2...re¬
freshed. . .and relaxed...3...halfway back...4...your eyes may begin to
flutter, refreshed and rlaxed...5...fully awake and comfortable."
(END OF TAPE SEQUENCE)
At this point, the subject will have an opportunity to ask ques¬
tions concerning the tape she just viewed. Following this, she will be
given a chance to learn and experience the relaxation techniques des¬
cribed and presented in the tape. The same induction format will be
utilized (the educational component will be deleted).
The suggestion will be made that if she would like to practice this
technique between sessions, it would be beneficial to her, her preg¬
nancy, and her offspring.

APPENDIX D
SESSION SUGGESTIONS
SESSION TWO SUGGESTIONS
1) Pregnancy will last until you, your body, and your child know
it is the time to begin the birth process.
2) You're looking forward to a happy, healthy child. Pregnancy is
a time to allow your child to become as healthy as possible within your
body. The healthier you are, the healthier your child will be...and the
healthier your child becomes, the better you feel.
3) The more relaxed you become now, the more you know that you
will want less anesthesia during your delivery than you had expected.
4) You can feel good about what you are doing right now, because
you know that as you learn to relax, you can enjoy your pregnancy,
delivery, and child more.
SESSION THREE SUGGESTIONS
1) The relaxation you experience now will be with you in the
future...during your pregnancy, delivery and future life.
2) You're looking forward to your expected delivery date, because
you know that within a few days of that time will be when you will
deliver the happiest, healthiest child you can.
3) Your delivery will be an exciting time, a time when you can
feel comfortable and relaxed, yet eagerly watching as you bring a new
life, your baby, into this world.
102

IUO
4) You are preparing your baby for birth right now. Your un¬
conscious will tell you when the time is right to begin delivery.
SESSION FOUR SUGGESTIONS
1) You're looking forward to a continued, pleasant, comfortable
pregnancy. The more you enjoy this pregnancy, the happier and healthier
you and your child will be, now and in the future.
2) The date your doctor said would be your delivery due date would
be a good time to begin the birth process, knowing that at that time you
can have a happy, healthy child.
3) The nearer you come to your expected delivery date, the better
you will look and feel, knowing you will deliver a happy, healthy child.
4) Your due date will be a good time to begin your contractions
and delivery of your baby.

APPENDIX E
PRENATAL CARE
Amelia C. Cruz, M.D.
1.First prenatal visit
-complete history and physical
-risk score - high or low
-Pap and CC
-check results of lab done at registration; if not done order
at this time - Type and Rh, Ab screen, Hct or Hb, Rubella,
sickle screen if black, bacturcult, VDRL
-screen for need for genetic counseling and refer
appropriately (see section on Genetic Counseling)
-advise about danger signs in pregnancy and mechanism for
emergency call or refer to OB nurse for details on this
-check tetanus immunization status; if no booster for 10
years give booster
-PPD - if status is unknown for population at risk
-history of herpes - see section on Herpes
2.If abnormal lab test refer to appropriate section in Manual.
3.Obtain ultrasound for dating as early as possible if:
dates unsure
BCP before LMP
dates = exam
high risk patient
weight 180 pounds
104

4.Return visits
-low risk patients
every 4 weeks up to 28 weeks
every 2-3 weeks from 28-36 weeks
every week from 36 weeks
-high risk patients
as often as needed (usually 1-2 weeks)
5.Glucose screen - see appropriate section for early screen
-all patients get 1 hour glucose screen at 28-30 weeks
-for MIC patients - see Dr. Mahan's memo
6.Rh negative unsensitized patients - repeat antibody screen at
28 weeks. If negative, give Rhogam 1 amp IM (see Section on
Rh negative). Order Rhogam on same blood sample as the 28
week screen. It should be given within 48 hours so the
patient must come back within 2 days otherwise the blood bank
will request another antibody screen before releasing the
Rhogam.
7.At 34-36 weeks - repeat GC culture and VDRL for high risk
group; Hct or Hgb for all.
8.Pelvic exam at 39-40 weeks for cervical status (Bishop
score).
9.If undelivered by 41 weeks follow protocol for postdates
pregnancy.
A. Cruz
8/82

APPENDIX F
STUDY DATA FORM
The Extension of Pregnancy through the Application of Counseling
and Focused Relaxation with Mothers at Risk For Premature Delivery
MOTHER'S LAST NAME
HOSPITAL NO.
MATERNAL AGE
PARITY
1 YEAR SINCE LAST PREG.
# OF CLINIC VISITS
FINANCIAL
CRUZ SCORE
CREASLEY SCORE
BIRTHWEIGHT
1 MINUTE APGAR
5 MINUTE APGAR
EST. GEST. AGE BY
MATURITY RATING IN WEEKS
CONDITION OF INFANT
INFANT'S HOSPITAL NO.
# DAYS STAY IN NB
1 = yes 2 = no
0 = self pay
1 = medicaid
2 = MIC
3 = POB
4 = insurance
0 = baby to newborn
1 = baby to NICU
2 = baby to inter¬
mediate nursery
106

IU/
# DAYS STAY IN NICU
# DAYS STAY IN ICN
RDS
—
1 =
yes
2 =
no
TTN
1 =
yes
2 =
no
HYPERBILRUBINEMIA
1 =
yes
2 =
no
FEEDING PROBLEMS
1 =
yes
2 =
no
CNS BLEED
1 =
yes
2 =
no
NEC
_
1 =
yes
2 =
no
PDA
—
1 =
yes
2 =
no
PREVIOUS OB COMPLICATIONS
PROM
1 =
yes
2 =
no
PREMATURE LABOR
1 =
yes
2 =
no
HYPERTENSIVE DIS
1 =
yes
2 =
no
INSULIN DEPENDENT DIABETES
1 =
yes
2 =
no
NON-INSULIN DEPENDENT DIABETES
1 =
yes
2 =
no
CARDIAC DIS
1 =
yes
2 =
no
RH DIS
1 =
yes
2 =
no
MULTIPLE PREGNANCY
1 =
yes
2 =
no
INCOMPETENT CERVIX
1 =
yes
2 =
no
FDIU
1 =
yes
2 =
no
PYELONEPHRITIS
1 =
yes
2 =
no
DES EXPOSURE
1 =
yes
2 =
no
UTERINE ANOMALY
1 =
yes
2 =
no
UNKNOWN BLEEDING
1 =
yes
2 =
no
PREVIA
1 =
yes
2 =
no
1 = yes 2 = no
ABRUPTION
I

108
PRESENT OB COMPLICATIONS
PROM
1 =
yes
2 =
no
PREMATURE LABOR
1 =
yes
2 =
no
INSULIN DEPENDENT DIABETES
1 =
yes
2 =
no
NON-INSULIN DEPENDENT DIABETES
1 =
yes
2 =
no
CARDIAC DIS
1 =
yes
2 =
no
RH DIS
1 =
yes
2 =
no
MULTIPLE PREGNANCY
1 =
yes
2 =
no
INCOMPETENT CERVIX
1 =
yes
2 =
no
UNKNOWN BLEEDING
1 =
yes
2 =
no
PREVIA
1 =
yes
2 =
no
ABRUPTION
1 =
yes
2 =
no
FDIU
1 =
yes
2 =
no
PYELONEPHRITIS
1 =
yes
2 =
no
DES EXPOSURE
1 =
yes
2 =
no
UTERINE ANOMALY
1 =
yes
2 =
no
HYPERTENSION
1 =
yes
2 =
no
BACTERIURIA
1 =
yes
2 =
no
WEIGHT LOSS OF 2 KG
1 =
yes
2 =
no
HEAD ENGAGED
1 =
yes
2 =
no
FEBRILE ILLNESS
1 =
yes
2 =
no
BLEEDING AFTER 12 WEEKS
1 =
yes
2 =
no
DILATION
1 =
yes
2 =
no
UTERINE IRRITABILITY
1 =
yes
2 =
no
PLACENTA PREVIA
1 =
yes
2 =
no
HYDRAMNIOS
1 =
yes
2 =
no
TWINS
1 =
yes
2 =
no

i vy-/
ABDOMINAL SURGERY _ 1 = yes 2 = no
WEEKS OF GESTATION
PROM 1 = yes 2 = no
DATE OF ROM
HOURS OF ROM BEFORE
DELIVERY INDUCED
# HOURS BETWEEN ONSET OF
CONTRACTIONS AND DELIVERY
AUGMENTED 1 = yes 2 = no
DATE OF DELIVERY
TYPE OF ANESTHESIA USED
TIME OF DELIVERY
METHOD OF DELIVERY 1 = vaginal
2 = c/s

APPENDIX G
CASE NOTES ON THE HYPNOTIC SUBJECTS
1) B.R. is a 25 year old black female with a history of one spontaneous
abortion and no live births. Problems in past pregnancy included gall
bladder, pylonephritis, and sickle cell anemia. Expressed limited
interest in the pregnancy and hypnotic treatment initially. Was adamant
initially that she did not wish to carry to term due to the perceived
discomfort of the latter stages of pregnancy. Walked out of the first
session of treatment which involved observing a videotape of a group
undergoing a hypnotic induction. In later sessions, B. identified the
benefits of "relaxation" in her daily life - stated she used it to calm
herself and also to deal with minor physical complaints (fatigue,
headaches, discomfort). B. carried to term.
2) K.C. is a 23 year old white female with a medical history of having
delivered a child suffering from Potter's Syndrome. This child died
some hours after delivery. K. initially expressed a great deal of
animosity and fear toward the medical community. The child's death had
been unexpected and she felt minimal support from the medical staff
during that episode. She expressed fear that this pregnancy would also
end in the death of her offspring. Initially broke from trance state to
reiterate the fears that this child would die. K. was an excellent
hypnotic subject who expressed having vivid imagery. Feedback from the
medical staff indicated that K. became an active patient, seeking assis-
110

tance and following through on scheduled appointments. Problems related
to her husband's typical absence from the home were alleviated when K.
delivered a healthy term child on a holiday with her husband present.
The child was named after the experimenter.
3) B.B. is an 18 year old black female with a history of diabetes and a
pre-term delivery in which the offspring did not survive. Although
insulin dependent, B. had a history of not taking her insulin due to
fear of needles. This eased somewhat during pregnancy. B. appeared to
be a difficult client with a short attention span which was exacerbated
by frequent interruptions during treatment sessions. B. carried to term
(36 weeks) before being induced due to the extreme diabetic condition.
4) F.M. is a 26 year old white female with a history of a preterm
delivery as well as an offspring born with ambiguous genitalia. F. was
considered a quiet, ready subject who expressed significant concern
about "losing" this baby. By the third treatment session, this anxiety
seemed to have dissipated markedly. Later sessions showed F. experien¬
cing deep trance state. Delivered at term.
5) R.K. is a 34 year old black female with a history of a preterm
delivery and two spontaneous abortions. R. expressed a great deal of
hostile feelings toward the medical staff, especially concerning her
last pregnancy when a cerclage had been used and not removed until late
in the delivery process. At that time, she had been "snipped" along
with the cerclage. During this pregnancy had again been given a
cerclage and feared similar negative results. An excellent subject for
treatment, R. maintained a trance state through numerous interruptions.

112
Was able to use historical awareness of having carried a fetus to 34
weeks to gauge her progress and later noted that she could identify
being "more pregnant" than ever before. In a follow-up conversation, R.
noted that she had "done a good job" in this pregnancy and had used the
hypnosis not only for pregnancy related issues but also to deal with
some marital stress. R. delivered at term.
6) S.W. is a 34 year old white female with a history of preterm
delivery, two spontaneous abortions, diabetes, and a chronic heart
condition. S. consistently expressed negative thoughts about this preg¬
nancy and the fetus. Was unsure whether the father of this fetus was
her first or second husband. There was also discussion of whether a
living child would be taken from her due to possible abuse issues. S.
was never felt to be a good or invested subject. S. delivered pre¬
maturely at 32 weeks. Following her delivery, S. underwent surgery to
replace a heart valve.
7) A.H. is a 26 year old white female with a history of two preterm
deliveries, a spontaneous abortion, and two neonatal deaths. After the
second treatment session, A. expressed confidence that she would carry
to term. A. showed a distinct change in attitude after eclipsing her
previous preterm delivery date in this pregnancy. She became more
relaxed and interested in the fetus at that point. An excellent subject
who held trance state through numerous interruptions. A. delivered at
term.
8) L.E. is a 23 year old black female with a history of a preterm
delivery and chronic hypertension. L. had experienced abruptio placenta

in last pregnancy and expressed fear and anxiety about both losing this
fetus and re-experiencing another frightening delivery involving exces¬
sive bleeding. With progression of sessions, expressed growing confi¬
dence in pregnancy and a sense of being "more in control". She
experienced the fear of death of self and fetus as date of previous
preterm delivery approached. Experienced some "false labor" at that
time. Went on to have a positive experience and deliver a term infant.
9) M.B. is a 29 year old black female with a history of a preterm
delivery, chronic hypertension, and a diabetic condition. M. was
identified as a good subject although always feeling rushed to leave
sessions. M. used the techniques at home and noted an increased ability
to experience peaceful sleep. M. noted this would be her "last chance
to get pregnant." M. carried to term.
10) D.P is a 27 year old white female with a history of a preterm
delivery. D. was a quiet, somewhat non-descript woman who appeared to
have some guilt concerning her past preterm delivery. Sessions were
often interrupted and D. seemed to react somewhat to these breaks. A
good subject in general, expressed very clear imagery. D. carried to
term.
11) C.C. is a 22 year old black female with a history of a spontaneous
abortion ending in a stillborn fetus. In all three prior pregnancies an
incompetent cervix had neen noted. C. expressed fear of losing this
fetus (last fetus had been stillborn). C. became an excellent subject,
and was considered a good clinic patient who maintained all scheduled
appointments during this pregnancy. C. expressed interest in this

114
pregnancy and noted clear, vivid imagery during sessions. C. delivered
at term.
12) K.M. is a 26 year old white female with a history of six spon¬
taneous abortions. K. was a compliant subject who left the area in her
last month of pregnancy. K. was a good subject and maintained a trance
state through numerous interruptions. She expressed some fears ini¬
tially about her history of spontaneous abortions and of the medical
community. These fears appeared to be reduced in later sessions.
Follow-up indicated that K. delivered at term.
HYPNOTIC SUBJECTS WHO DID NOT COMPLETE PROTOCOL
L.J. -delivered prematurely within the week following the initial
session involving observation of videotape.
D.D. -delivered prior to completion of 2nd session of treatment program.
D. had expressed fear and belief during 1st session that she would
deliver prematurely.
J.B. -delivered prematurely within two weeks following the initial
session.
T.M. -refused to continue after first session. Identified that the
treatments took "too much time." Resistant to appointment at the
clinic.
R.F. -delivery medically induced prematurely due to chronic hyper¬
tension, rheumatic heart disease, Class I cardiac disease and pre¬
eclampsia. Pitocin induction ordered at 32 weeks. (Severe history of
medical and psychological disorders).

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BIOGRAPHICAL SKETCH
Marshall Lloyd Knudson was born on February 27th, 1952, in
Austin, Texas. At an early age he moved to Arlington, Virginia,
where he graduated from high school in 1970.
He attended the University of Virginia, where he became a
founding member of The Bears and received a Bachelor of Arts
degree in 1974. He received a Master of Science degree in
clinical psychology from Mississippi State University in 1975.
In 1976 he enrolled at the University of Florida, where he
continued graduate study toward the doctoral degree in counseling
psychology.
He has a wife, Laura, and a daughter, Heather.
125

I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.
Paul J. Witimer, Chairman
Professor of Counselor Education
I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.
Paul G. Schauble
Professor of Psychology
I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.
Harry A. Grater, Jr.
Professor of Psychology
This dissertation was submitted to the Graduate Faculty of the Department
of Counselor Education in the College of Education and to the Graduate
Council, and was accepted as partial fulfillment of the requirements for
the degree of Doctor of Philosophy.
April 1984
Dean, Graduate Studies and Research

UNIVERSITY OF FLORIDA
3 1262 08556 8920



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