The use of hypnosis in obstetrics and surgery is not new. More than a century ago, mesmerism or hypnosis was one of the principal technics of pain relief for delivery. It was unfortunate that the discovery of inhalation anesthesia, in the middle of the last century, relegated hypnosis to underserved oblivion.
There has been a resurgence of interest in hypnoanesthesia.29,31,32,50 However, as stressed throughout this book, it will never be a panacea, nor will it ever supplant chemoanesthesia in parturition. Nevertheless, as the late J. B. DeLee once stated: “The only anesthetic that is without danger is hypnotism … I am irked when I see my colleagues neglect to avail themselves of this harmless and potent remedy.”15 Obstetricians are finally becoming aware of the use of hypnosis for obstetrical anesthesia as an adjunctive technic, as evidenced by the increasing number of reports.39,51,53,54
SUSCEPTIBILITY OF THE SUBJECT
Unfortunately, hypnoanesthesia per se is effective in less than 20 per cent of selected patients. However, in this group, episiotomy, forceps delivery, and repair can be performed withoutanalgesia or anesthesia. Approximately 50 per cent more can be carried through labor and delivery by a combination of hypnosis and drugs, preferably regional block. Where hypnosis potentiates chemoanesthesia, the combined method is better for this group than either method alone, as it permits a reduction of from 50 to 75 per cent in chemoanesthesia.
Conventional procedures are used for relieving pain in the remaining group, who are failures as far as hypnoanesthesia is concerned. However, by virtue of their exposure to prenatal hypnotic training, the majority of these are more cooperative and usually more relaxed, and regard their delivery as a most gratifying experience. Tom, who believes that hypnosis has a limited use in labor, comments, “It is interesting to note that, regardless of the results, all but one of the [73] patients thought that hypnosis was worthwhile and a great help during labor, and all wanted to use hypnosis again for the next delivery.”51 The exception was a patient who had an improperly conducted labor. Thus, even when hypnoanesthesia is only partially effective, repeated suggestions with or without medications can mitigate the discomfort of labor. This is not surprising, as there are two routes for pain transmission—one physical, the other emotional. With chemoanesthesia, only the physical route for perception of painful stimuli is blocked.
Strong suggestion and/or hypnosis effectively blocks the emotional pathway for apperception of painful stimuli.
PERSONALITY FACTORS IN SUGGESTIVE ANESTHESIA METHODS
Candidates for both hypnosis and the “natural childbirth” method have been studied.44 The author includes the Velvoski or psychoprophylactic relaxation method,6,10 education for childbirth,22the Lamaze method,33 and the hypnoreflexogenous method47 in the same category as natural childbirth—all are based on similar principles directed toward reducing anxiety by counterconditioning it with relaxation. In addition, these methods include a form of systematic desensitization to mitigate the fear of childbirth. These patients often have similar personality profiles as well as an identical need for these procedures. They usually have a high degree of compulsiveness and a desire to please the father-figure (the obstetrician). Generally, their choice of these methods is based on multiple factors of which fear of childbirth is only a superficial aspect. Other reasons are fear of pain in general, fear of death while unconscious, fear of losing control of themselves and injuring the baby, fear of what might be said when they lose consciousness, curiosity as to the birth process, and fear of pain as a punishment in cases in which the pregnancy is unwanted.
It has been contended that an emotionally mature attitude toward pregnancy is generally dependent on healthy psychosexual development. When a female approaches menstruation, marriage, sex, and motherhood with fear, it is only natural to expect anxiety during pregnancy and labor. Also, women who have rejected the feminine role, either because of latent or overt homosexuality or fixation at earlier levels of personality development (the infantile adult), are more than likely to have inordinate need for pain relief during childbirth. Unfortunately, too few patients seek the suggestive methods which are the methods of choice for a safe labor—both physically and psychologically—for mother and child.
COMPARISON OF HYPNOSIS, “NATURAL CHILDBIRTH,” PSYCHOPROPHYLACTIC RELAXATION, AND OTHER METHODS
There is no doubt that the expectation of pain and fear associated with labor can be effectively relieved by suggestion and/or hypnosis. Education for childbirth by the “natural childbirth” methods or the other procedures mentioned above are aimed at establishing healthy attitudes and have the same purpose as hypnosis but cannot achieve as deep a relaxation or reduce discomfort to the same degree as the latter. Even the most ardent enthusiast of natural childbirth or the Lamaze method would not advocate it for major surgery.
An experienced observer will recognize that successful natural childbirth patients have been hypnotized to a degree; some have reached at least a light stage, and others a medium stage of hypnosis. For the most part, this is achieved without their being aware of it and usually without the knowledge of the obstetrician. Grantly Dick-Read remarks that many of his patients appear as if in a trance during the latter part of the first stage.16 Thus, when natural childbirth and hypnosis are compared, it is obvious that both employ suggestion to raise the patient's pain threshold. Optimal results are attained, however, when the educational aspects of natural childbirth are combined with hypnosis to raise the pain threshold.
Psychoprophylactic relaxation, as recently developed in the Soviet Union, is yet another method of training or conditioning for childbirth, based on the principles of hypnosis and group dynamics. Those who have observed these classes in the Soviet Union have stated that the patients become absorbed in the instructions of the doctor, that his voice and manner are those of an experienced hypnotist, and that the appearance of those in attendance resembles that of persons in various states of hypnosis.5 The total picture is one of confidence and faith. Oxygen administered by inhalation also has a highly suggestive effect. Since every citizen in the Soviet Union has heard the name of Pavlov since childhood, the element of prestige is high in any indoctrination method proposed by this eminent scientist. At the very least, it affords a definitive approach to eliminate fear about labor and delivery.
In a similar manner, in thousands of women, the educational and training methods establish a “power of positive thinking” about childbirth—a favorable mind-set. The prestige factor, along with belief, faith, confidence, the mind-set, and expectant attitude, provides the very basis for a hypnotic relationship. In psychoprophylactic relaxation, natural childbirth, progressive relaxation, autogenic training, and hypnosis, misdirection is produced by the various exercises learned in the classes, and these help to raise the pain threshold. Hilgard and Hilgard caution that even though the natural childbirth methods and hypnosuggestive methods overlap, there may be differences.26 They state that “It is quite possible that the Read exercises can be taught satisfactorily to women who, in a strict sense, are not hypnotizable, even if more hypnotizable women achieve a state indistinguishable from hypnosis.” They further discuss eight characteristics of hypnotic procedures in childbirth: (1) employment of a rehearsal procedure, (2) relaxation for deepening the hypnotic involvement, (3) use of symptom substitution, (4) displacement of the pain elsewhere, (5) direct suggestion of symptom relief, (6) indirect suggestions as glove anesthesia, (7) imaginative separation of the painful uterine contractions via fantasy evocation, and (8) posthypnotic suggestions to instill confidence.
ADVANTAGES OF HYPNOSIS
The benefits and the advantages of hypnosis in obstetrics are legion:
1. Reduction or eradication of fear, tension, and pain before and during labor with a consequent rise in the pain threshold.
2. Reduction of chemoanalgesia and anesthesia or their complete elimination in good hypnotic subjects.
3. Complete control of painful uterine contractions; the mother can choose to experience the sensations of childbirth or not, as she sees fit.
4. Decreased shock and speedier recovery.
5. Lessened incidence of operative delivery since the responsive patient cooperates more fully, particularly during the expulsive stage. Relaxation and anesthesia of the perineum are produced by autohypnosis or by direct suggestion from the hypnotherapist; this eases delivery, episiotomy, and suturing of the perineum.
6. Lack of undesirable postoperative effects such as may be encountered with drug anesthesia; hypnoanesthesia is also more readily controlled.
7. Hypnosis shortens the first stage of labor by approximately 3 hours in primiparae and by more than 2 hours in multiparae.
8. Hypnosis raises the resistance to fatigue, thus minimizing maternal exhaustion.
9. Hypnosis can be used in debilitated individuals, in those who have ingested food shortly before delivery, and in those who are allergic to drugs. Also, it is indicated in premature delivery.
10. Hypnotic rapport can be transferred to an associate, an intern or a nurse, or to the husband, any one of whom, without previous training, can readily induce and maintain the hypnotic state by means of a prearranged cue (this can be accomplished only with the patient's permission).
11. No elaborate education or ritualistic exercises are needed to achieve the strong interpersonal relationship essential to the success of childbirth under hypnosis. These are required in such pain-relieving technics as natural childbirth and psychoprophylactic and progressive relaxation, which are merely modifications of the hypnotic method.
12. There is no possibility that harm will be done to the mother or the baby by hypnoanesthesia. On the other hand, the literature offers a considerable amount of evidence that when drugs are given for pain relief they may decrease the oxygen supply to the fetus. Combined with other asphyxial factors such as trauma or difficult delivery, this may produce fetal anoxia and, in its wake, severe brain damage. With hypnoanesthesia, the danger of fetal anoxia is markedly decreased.
13. Childbirth under hypnoanesthesia is an intensely gratifying emotional experience for well-adjusted mothers. Hearing the baby's first cry or seeing him immediately after birth are thrills that mothers can never feel if they are “knocked out.”
14. Hypnosis can be life-saving for mother and baby in obstetrical emergencies. Its successful application has been reported in abruption placenta with delivery of a live baby.24
If these advantages were more widely known, more mothers would have their babies by hypnosis. If the pain threshold can be lowered by the anticipation of pain, it can be raised by eliminating the expectation of pain through hypnotic suggestion.
For generations, women have been “hypnotized” into thinking that they must have severe pain in childbirth by older, sadistic females who relate their “harrowing” experiences to impressionable young girls. Women do have pain in childbirth but, through appropriate training, they can be “dehypnotized” of these notions to reduce or eliminate the fear-tension-pain syndrome. In this manner, childbirth becomes a joyous experience which fulfills many of their unrecognized and unformulated needs.
Moya and James recently reported on the clinical and biochemical studies of 21 infants born to mothers under hypnosis, and compared these infants with a group of babies born under various anesthetic technics.39
They stated:
Serial determination of the acid-base status after birth showed a significantly greater ability of the hypnosis group to readjust rapidly and to recover from the asphyxia of birth … These data indicate a definite superiority of the hypnosis group in establishing and maintaining effective ventilation which was not revealed by careful clinical examination alone.
DISADVANTAGES AND CONTRAINDICATIONS
Hypnosis is not without limitations and contraindications:
1. Despite the high percentage of people susceptible to some type of hypnosis, maximal relief of pain and discomfort can be achieved in only one out of four patients. This limits the application of hypnosis as the sole anesthetic.
2. Hypnotic induction can be affected easily by psychological factors: well-prepared hypnotic subjects often “go to pieces” when exposed to other screaming women in various stages of labor; good subjects are often “talked out of it” by apparently well-meaning friends and neighbors.
3. The added time required to achieve the rapport and the depth of hypnosis necessary for operative procedures is a potential problem. It can be solved, however, as group training for hypnoanesthesia becomes more widespread and more trained personnel become available.
4. A trained hypnotherapist must be available throughout the entire labor unless the patient can induce autohypnosis.
5. The prevailing misconceptions about hypnosis held by the laity prevent many patients from being more susceptible to hypnotic suggestion.
6. Hypnosis is contraindicated in a deeply disturbed individual, either psychotic or borderline-psychotic, except when employed by a therapist trained in psychiatry. However, there is little possibility that hypnosis per se can precipitate a psychosis. Most psychotics are difficult, almost impossible to hypnotize, but if they prove susceptible, the dangers are minimal.
Tom mentions five patients in whom neurosis or psychosis was exacerbated or precipitated, all stemming from the work of one doctor, who had been emotionally ill.51 These cases are not documented, and it is obvious that, if a doctor is sick, he should not practice medicine.
7. Inappropriate remarks made to a hypnotized individual or a faulty interpersonal relationship between the hypnotist and the subject can be damaging. However, these dangers can arise at nonhypnotic levels in similar circumstances and they are always to be avoided.
8. Some psychiatrists contend that hypnosis fosters extreme dependency. This may be true, but a strong bond of dependency exists in every doctor-patient relationship, especially in obstetrical practice. This dependency is only temporary, however, and can be used to advantage during the early prenatal period to establish greater confidence in the obstetrician. As the patient is taught autohypnosis, the dependency is more or less dissolved.
PREPARATION OF THE PATIENT
When a woman asks to have a baby under hypnosis, there are three things that the hypnotherapist must ascertain: her reasons for choosing this form of anesthesia; possible contraindications, depending on her personality type; and her responsiveness to hypnotic suggestion.
DETERMINING RESPONSIVENESS
Since some patients are not susceptible to hypnosis per se, it is important for the therapist to ascertain the degree of rapport he can achieve and to assess the potentialities for hypnosis. This can be accomplished by attempting to induce a hypnotic state and then offering a posthypnotic suggestion. If the suggestion is followed, hypnosis is established. Subsequent training for deep hypnosis is not time-consuming if a posthypnotic suggestion to go deeper the next time is made during the initial session.
Hypnosis cannot be induced in some patients, due to a lack of motivation or rapport between them and a particular therapist. Rapport may be strong with one therapist and weak with another. It may even vary with the same therapist.
Hypnosis should never be attempted until a preliminary discussion has been held to remove all misconceptions and to enlighten the patient about hypnotic childbirth. The patient should be told that hypnosis does not always work by itself; that if only 20 per cent are partially successful, this is 20 per cent better than nothing; that the degree of success depends on the motivation; and that autohypnosis and the production of glove anesthesia are phenomena achieved by the patient.
If patients are doubtful, I generally remark: “Why not come to one of my prenatal classes and see what it's all about? If you think you wish to have your baby under hypnosis, you can join a class. Naturally, the more sessions you attend, the more you will understand about hypnosis. Then you can decide if you wish to continue.”
REASONS FOR CHOOSING HYPNOANESTHESIA
Often a pregnant woman's reasons for choosing hypnoanesthesia may not be apparent. Many emotionally well-adjusted women who have an ardent desire for motherhood are seeking hypnotic childbirth. The majority of these women have a strong wish to experience all the pleasant feelings associated with delivery such as hearing the baby's first cry. Others wish to be fully aware and cherish the memory of this climactic event. These are bona fide reasons for seeking this type of delivery.
On the other hand, there are some women who seek hypnoanesthesia who should be rejected because they are overzealous. Such patients usually have deep-seated feelings of inadequacy which they hope to lose by undergoing hypnosis—which is in their eyes a unique and, therefore, an ego-building experience. When these women are unable to get through labor and delivery under hypnosis alone, they feel a sense of failure and may become severely depressed. This is not an indictment of hypnosis. It is just something that every practitioner of hypnosis should keep in mind, so that he will be alert to underlying personality disorders in prospective subjects. In working up the obstetrical patient who desires hypnoanesthesia, personality appraisal should be as routine as pelvic measurement.
TRAINING IN HYPNOSIS
Training in hypnoanesthesia may be carried out in private office sessions or in group training classes. In either case, the patient does not have to read extensively, carry out elaborate exercises, or necessarily be educated in the mechanisms of labor. She must only attend a varying number of sessions with the doctor, during which her pain threshold is raised and her hopes for an easy and uneventful delivery are enhanced.
All patients should be informed that analgesia and anesthesia will be available on request, should they need it. Moreover, they should be advised not to feel guilty about asking for it. They should also be told that they do not have to go through the entire labor and delivery under hypnosis per se just to please the therapist who, it should be explained, will not feel “hurt” if they require help. It should be stressed again and again that the purpose of hypnosis is to minimize, not to eliminate drug requirements. Since fewer than one out of four will be able to do without drugs altogether, none should be made to feel that they have to “sign a pledge” against anesthesia.
Ideally, hypnotic conditioning should begin during the third or the fourth month of pregnancy. The patient is hypnotized two or three times a month until maximal hypnosis is achieved. Exactly how many visits a patient will require before one can feel confident of satisfactory anesthesia is uncertain. It may vary from one to 20 or more sessions. Usually, if anesthesia is not obtained after 10 visits, the outlook for success is poor. Patients should be informed in advance that numerous sessions may be required to obviate discouragement.
During the conditioning period, the patient is taught auto- or self-hypnosis and “glove anesthesia.” At each session, posthypnotic suggestions emphasize that the patient need have no more discomfort than she is willing to bear. Repeated conditioning enables the patient to reach deeper states of hypnosis and raises her pain threshold. Suggestions are made that she will look forward to her confinement with a feeling of joy and happiness instead of dread and apprehension. The more these posthypnotic suggestions are repeated, the more effective they become. The patient is told repeatedly that when labor begins she will promptly fall into deep hypnosis in response to a given cue—usually the touch on the right shoulder. With adequate preparation, a patient can enter into deep hypnosis in a matter of seconds by the shoulder signal. Glove anesthesia is best achieved through autohypnosis, and the area to be desensitized is chosen by the patient. This permissive approach directed toward teaching the patient to be self-reliant should stop the criticism that hypnosis fosters extreme dependency on an authoritarian figure.
Response to posthypnotic suggestions and production of autohypnosis and glove anesthesia during the prenatal training period presumptively indicates that the patient is ready for all stages of labor. An Allis clamp or a sterile needle may be used for testing the degree of anesthesia present in the perineum or the abdomen. Complete anesthesia during parturition is often accompanied by disassociation and amnesia, the active use of which is optional. For example, amnesia for part or all of the labor can be induced or removed in good hypnotic subjects according to the previously expressed wishes of the patient.
Verbalization for Glove Anesthesia
Glove anesthesia is produced as follows: “And now you will go into a deep, hypnotic state, way down, deeper and deeper! You are going to produce glove anesthesia. As I stroke this hand, it is going to get numb, heavy, and woodenlike. When you are sure that this hand has become numb, just as your gums would be after your dentist has injected procaine, you will then transfer this numbness to your face. With every movement of your hand toward your face, it will get more numb and woodenlike.” (The hand moves to the side of the face.) “When it touches your face, press the palm of your hand close to your face” (the hand lifts and is pressed to the face), “and when you are certain that that numbness has transferred from your hand to your face, drop your hand and your arm. You are going deeper and deeper relaxed with every breath you take. You can just feel that numbness being transferred from your hand to your face. That's fine. Just fine. Excellent. Now, after you are certain that the area on your face is numb, you can remove your hand and it will be normal but your face will be anesthetized.”
The glove anesthesia can be transferred to the abdomen by one or both hands. A posthypnotic suggestion can be given that the anesthesia can be transferred to the perineum at the appropriate time. As each site is anesthetized, the sensory proof of anesthesia can be demonstrated to the patient. However, one should remark, “Remember, you will know what I am doing, but you will feel no pain as I test for the degree of anesthesia.” This is consistent with what is known of the phylogenesis of the nervous system.
Since pain is the most primitive of all sensations, it does not have as much cortical representation as the other senses. Discriminatory sensations such as touch, having been acquired later, have more representation in the cortex.
MANAGEMENT OF LABOR
When labor actually begins, the patient induces autohypnosis. The physician also can induce hypnosis over the phone, or through another physician to whom he has transferred the rapport. An assistant, such as a nurse, can do it by handing the patient a written order to go into a deep state of relaxation. How it is done depends on the kind of conditioning and the cues the patient received during her training program. If the patient has not mastered autohypnosis, the doctor's presence is necessary for maintaining the hypnosis. Suggestions are given for complete anesthesia of the abdomen, the perineum and other hypersensitive areas.
The following is an actual verbalization taken from a tape recorder for the conduct of labor: “Now, Mary, you have been able to enter a deep state of relaxation through autohypnosis. Also, you have demonstrated that you can produce glove anesthesia and transfer this numb, heavy, wooden feeling to either side of the face. Now that you are in active labor, you will be able to develop the same anesthesia in both hands and transfer this numb, heavy, wooden feeling to the abdomen, in order to cut down the discomfort produced by your contractions (the word ‘pains’ is never used). You will also develop anesthesia of any other area of the body that I pick out, such as the area between the vagina and the rectum. This area will be without any feeling for a considerable length of time. Each time you practice producing the glove anesthesia, you will be able to maintain it for long intervals. When labor starts, you first will feel an ache which will begin in the back and then it will move around to the side of your belly. At this time, you will be able to use the autohypnosis and place yourself in a deep state of relaxation. Remember, you need have no more discomfort than you are willing to bear. Your labor contractions will get stronger and longer, and that is a good sign that you are making progress. Even though you know that the labor contractions are there, you will not be able to feel them. If the glove anesthesia does not relieve your discomfort completely, please do not feel guilty about asking for drugs, which will be available.”
Eliminating the discomfort of labor does not impair those sensations and experiences that are a healthy part of natural parturition. A well-trained and responsive patient, freed of pain and discomfort, can dehypnotize herself for as many contractions as she wishes. Although she appears relaxed and “asleep,” she is actually fully aware during the labor and the delivery process, and participates emotionally in these; she can hear her baby's first cry, and see it immediately.
Subjectively, the contractions are felt as a tenseness of the abdomen and the bearing-down sensation as a slight perineal pressure. Spontaneous or operative delivery is often managed with the mother fully aware of what is going on, no matter whether the operative procedure is major or minor. Patients who are not so responsive naturally do not do so well during labor and delivery.
Hypnotic age progression has been used to hallucinate a pleasurable birth experience a priori, such as hearing the baby's first cry.9 It was used in 100 parturients, emphasizing relaxation rather than analgesia.1 The first and second stages were definitely shortened, and hypnosis and relaxation produced a more favorable result than relaxation per se. Relaxation provided a more pleasant experience than controls which did not have either one.20 Displacement of the pain from the uterine contractions with concomitant tightening of the hand-clasp during each labor pain is recommended by August.3 He also suggests imagery of past pleasant experiences, especially those involving long trips, gardening, fishing—any fantasy that will take the place of the actual painful contraction. In 1,000 patients, 850 were successfully delivered by these technics.3 The superiority of hypnosis over the Read method was demonstrated in 210 women.14 Hypnosis worked better even if it was initiated during the initial stages of labor for the first time.46 Nearly all past and current methods of antenatal training have been evaluated. It is concluded that it is not so much a matter of suggestions, relaxation training, and breathing exercises used, but rather that highly motivated parturients are taught how to behave during parturition and to expect less medication.13
With reference to hypnotic responsiveness and its relationship for determining its effects, the data are often contaminated by many factors. For instance, if the obstetrician is present during the labor, this often is the equivalent of a quarter gram of morphine. The degree of cervical relaxation, the size of the birth canal, and other anatomical factors, such as the position and molding of the presenting part (occiput or breech), are other imponderables. The author has discussed many of these factors in his numerous publications as well as in a film.*
Other practitioners have found hypnosis to be valuable in obtunding pain during delivery.11,12,14,27, 34,35,37,38,40,41,52 The emotional support parturients receive during the prepartum period also has been stressed.50
HELPFUL SUGGESTIONS DURING LABOR
It takes years of practice to become adept with forceps or to be a good vaginal operator. Likewise, the ability to be adept in producing, maintaining, and controlling the applications of hypnosis to obstetrics requires much practical experience. The most useful suggestions are given below.
Misdirection of attention is used to mitigate the forcefulness of the labor contractions, as follows: “I want you to breathe deeply in the same manner in which you were trained during the prenatal classes. You will count the number of deep breaths or pants that you take with each contraction. In other words, as soon as you feel the contraction, start panting and keep a record of the number of breaths required for each contraction. Perhaps it might be 28 for the first one. In about 10 minutes, you should have another contraction which may last for 30 or 40 seconds; this one may require 30 deep breaths or pants. Keep an average between the first and the second by adding the total and dividing by 2, which, in this case, would be 29. I want you to keep this average for all of your contractions. As they get closer and closer, you will notice that the average number of breaths will increase, indicating that labor is progressing nicely.”
The idea is to keep the patient's attention so concentrated on the addition and the division that she doesn't have time to think of the painful uterine contractions. Such a procedure can potentiate the use of hypnosis. This preoccupation undoubtedly explains to a degree the success of the natural childbirth method in which the individual spends a considerable amount of time thinking about whether or not she is carrying out this or that exercise correctly. “Finally, when you are in the last stages of labor, you will push down when requested to do so. Naturally, the more you relax, the more effective each push will be. If you follow these suggestions you will get the most out of each contraction.”
Another way to deepen the hypnosis is to employ the husband's participation and posthypnotic suggestions: “I am going to instruct your husband that each time you develop a contraction, he will squeeze your wrist with his forefinger and thumb. And, as he squeezes your wrist, this will be a cue, or a signal, that you will drop deeper and deeper relaxed with each deep breath you take.”
Backache in the sacral area causes considerable discomfort, especially if the fetus is in an occiput posterior position. Here, too, the husband's aid can be enlisted: “I want you to place the palm of your hand, with your fingers fanned out, over the small of your wife's back. You will press firmly over this area. You will start this at the beginning of each contraction and release the pressure only after the contraction has disappeared.” This maneuver often helps patients who complain bitterly of low back pain.
“If you do have more discomfort than you are able to tolerate, do not feel embarrassed if you have to moan. It will help relieve some of the tension. Also, if you wish to open your eyes, you may do so without interfering with the relaxed state you are in. As soon as you close your eyes, you will drop even deeper relaxed. You will not be bothered by any noises or sounds around you. As a matter of fact, you will become more and more concerned with your breathing and counting, and, as you become more involved in these, the sounds around you will fade into the distance. As the head of your baby descends down the birth canal, you will notice more of a desire to push. I have taught you how to breathe. You can grunt and bear down. Every contraction will be a signal for you to bear down harder. And, because you will be completely relaxed, you will obtain the maximal effect from each contraction. You can go through the rest of your delivery without any trouble. Remember, if you should require an anesthetic agent, it will be given to you. And, even if this is necessary, you will find that having a baby will be an exhilarating experience, especially if you are deeply relaxed.”
For the actual delivery, the patient can transfer the glove anesthesia to the perineum before it has been “prepped” or sterilized. She is instructed: “This area will remain completely numb and anesthetic. As you push down, with each deep breath you take this area will become more and more anesthetic.” One can also produce anesthesia by commenting: “As I stroke this area with my fingers, it will become numb and anesthetic, completely numb and anesthetic, just as if this area had been injected with procaine. It will become just as numb and anesthetic as your jaws become after the dentist has blocked off a nerve. This area is getting very numb, heavy, and woodenlike.”
One can enhance the anesthetic effects of the above methods, after the vagina has been sterilized and the patient is ready for delivery, by the following suggestions: “I am now freezing all the skin between my thumb and forefinger.” (Considerable pressure is exerted at this time.) “Everywhere I touch my thumb and forefinger together, you will notice a numb, heavy, woodenlike sensation that will get more numb with each breath you take.” This, together with the delivery of the head, produces a considerable amount of pressure anesthesia which, in some patients who have a high pain threshold, is sufficient for the performance of an episiotomy.
Approximately 5 per cent of patients have high sensory pain thresholds; the pressure anesthesia is especially effective for this group. About 10 to 15 per cent, which includes this group, can have an episiotomy performed without analgesia or anesthesia. The combination of a paracervical and transvaginal pudendal block with hypnosis is the ideal prescription for painless childbirth. It is almost 100 per cent safe and enables the mother to participate emotionally in the birth process.
HELPFUL SUGGESTIONS FOR THE POSTPARTUM PERIOD
The glove anesthesia technic can be effective during the postoperative period for relief of perineal pain in an episiotomy produced by swelling. In a multipara, autohypnosis and glove anesthesia can be most effective in relieving the pain of postpartum contractions. The same suggestions as described in Chapter 14 are given.
INDUCTION OF LABOR BY HYPNOSIS
Labor can be induced by appropriate posthypnotic suggestions given to selected patients.7 The author has induced labor in the multipara capable of entering the somnambulistic state of hypnosis.32 The patient is regressed to her last labor and delivery. In this way it is possible to revivify all the subjective sensations associated with the onset of labor, thus “tricking” the autonomic nervous system into initiating the uterine contractions. It is difficult to do this in the primipara as she cannot imagine memories which she has never experienced. Reynolds has been able to correlate the amplitude of the uterine contractions with suggestions of relaxation or contraction during deep hypnosis.45
Often, premature labor can be prevented by strong reassurance and deep relaxation under hypnosis. The author used hypnosis to prevent premature labor in a case of abruptio placentae reported by Hartman and Rawlins.24
GROUP TRAINING
Group training in hypnoanesthesia is a time saving procedure for the busy obstetrician. The classes can be conducted by a nurse or a doctor. Motivation is heightened by the emotional contagion that occurs as patients identify and empathize with each other and by the spirit of competition that is mobilized within the group. Also, most patients undergoing group training attempt to please the doctor, and this is an added motivational spur.
The author's patients attend group training classes twice a month for 2 hours in the evening with their husbands. The first half hour is devoted to questions and answers on pre- and postnatal care, labor, delivery, kinds of anesthesia, and hypnosis. Patients are instructed that all questions, except those of a personal nature, are to be asked in the class. This saves valuable office time for the physician. Then several patients who have recently been delivered are asked to relate their experiences during labor. Their forthright and sincere discussion is highly motivating to the rest of the group.
Following these “testimonials” and the question-and-answer period, four or five patients who are good hypnotic subjects volunteer to illustrate how readily hypnosis can be induced. After induction, they are asked to induce autohypnosis and glove anesthesia. The way in which autohypnosis and glove anesthesia are produced is explained to the group. Once the glove anesthesia is transferred to the side of the face, the abdomen or the other arm, the insensitivity to pain is demonstrated. All patients alert or “awake” themselves; then four or more unsophisticated patients are asked to volunteer. Since a few minutes of observation of hypnotic induction is worth hours of talking about it, the beginner's susceptibility is increased. About 75 per cent of this group usually are hypnotized readily.
Platonov, in the Soviet Union, employed individual and group hypnosis to prepare large numbers of women for painless childbirth.42 He quotes numerous investigators who reported on the successful use of hypnosis with results similar to this author's. Among these are the enormous numbers of women delivered over the last 20 years in Leningrad by Vigdorovich, an obstetrician who supervised 15 “hypnotariums,” which were under the jurisdiction of the Leningrad City Board of Health. Painless childbirth was effected in 4,575 cases with 91 per cent positive results; toxemias of pregnancy were relieved in 95 per cent of 400 cases, and 126 false pregnancies were treated in these hypnotariums. With this impressive array of evidence, why are obstetricians in the West still “dragging their feet”?
NAUSEA AND VOMITING
Hypnotic Management
The dictum to “treat the patient who has the vomiting rather than the vomiting” is important. Nausea and vomiting and even hyperemesis gravidarum are astonishingly susceptible to hypnosis.
The incidence of cure in over a hundred patients seen in the author's private and clinic practice for a period of almost 45 years is approximately 75 per cent. Some, in spite of medical aid, were extremely toxic, with high icteric indexes, and some were almost moribund. Over 75 per cent of those for whom therapeutic abortion was considered were cured by hypnosis.30 Platonov treated 583 grave cases of hyperemesis gravidarum and cured over 84 per cent with an average of 7 hypnotic treatments.43
Psychogenic factors are chiefly responsible for the majority of cases. Hyperemesis gravidarum is unknown in some cultures, such as the Asian, but it develops in these peoples after assimilation into Western society.
In predisposed individuals, the gastrointestinal tract is symbolically utilized as a way of showing disgust—by vomiting. This is substantiated by the observation that the gut is a common site for the expression of disgust. Many of our vomiters had a strong aversion toward sex or an overdependent attachment to the mother; there was often a history of “rejection dyspepsia.”
Nausea and vomiting of pregnancy usually cease by the fourth or the fifth month, at which time the fetal movements are felt. The mother now becomes aware that the fetus is a separate individual and can no longer be “thrown up.” Thus, there is insufficient time for any uncovering psychotherapy. A differentiation between the “nervous” and the “toxic” type depends not only on the history but also on the laboratory findings.
Treatment should be directed primarily toward the patient as a whole, and not toward the symptom! The judicious use of hypnotherapy to establish the need for the symptom, combined with adequate medical management, is indicated for all cases of hyperemesis gravidarum. This often has obviated the need for therapeutic abortion. The author demonstrated this in a series of desperately ill women—the salvage rate was 85 per cent.19,30
Hypnotic Management Technic
After a patient has been hypnotized and taught autohypnosis, the following verbalization can be used: “You will notice that as you relax yourself through autohypnosis, your nausea and vomiting will decrease. You can also suggest that you will find it extremely difficult even to become nauseated or to vomit upon arising. Perhaps you might like to imagine that you are eating a delightful meal without getting sick. How about ‘eating’ something you like right now? You can see the food, can you not?” (The patient nods her head.) “Imagine, if you will, that you are eating the food and thoroughly digesting it. You will find that your stomach will be very, very relaxed if you look forward to eating; that it will be extremely difficult to vomit. Perhaps you would like to believe that no matter how hard you try, you cannot vomit. After you have practiced ‘eating’ enough times and have imagined that the food is going to stay down, you will enjoy it. However, if you really have to be nauseated, why not permit yourself to develop this sensation for 15 minutes every morning, especially in the bathroom? Then each day you can suggest that the time will be cut down by 1 or 2 minutes, so that at the end of a week or two you will wean yourself from the ‘need to vomit.’ Or, perhaps, you can increase the vomiting. You realize that if you deliberately increase your sickness, you are controlling it, and anything you can increase, you can decrease!”
“Now there are many needs for your nausea and vomiting. Perhaps you might tell me of some of your fears, anxieties and tensions in regard to pregnancy, delivery or care of the child. If you think of any problems concerning your pregnancy and delivery, relate them to me on your next visit. Regardless of how silly or inconsequential these thoughts may seem to you, tell me all about these matters. Then you will notice that with each day you will have less need to get sick. You can then look forward to having your baby with a feeling of joy and happiness.”
Glove anesthesia can be utilized as follows: “You have learned to develop an anesthesia of the palm of your hand. You are aware that you can transfer this sensation to any portion of your body. Every time you develop the slightest nausea, all you have to do to relieve it is to transfer this numb, woodenlike feeling to your stomach. Just press firmly on the pit of your stomach and the entire area will feel very, very relaxed.”
It is really surprising how effective this type of placebo therapy—in the form of “laying on of the hands”—is in abolishing the nausea and the vomiting. The patient's confidence and self-esteem are increased when she realizes that the “power” to eradicate the symptom is hers, and that no dependency on drugs or the doctor is required.
There are cases in which the vomiting persists even after an abortion. Here, the vomiting pattern is fixed in the cortex. This is similar to the pain pattern of phantom limb pain, and indicates the importance of altering the deranged cortical dynamics. Such psychopathology is more amenable to hypnosuggestive procedures because the vicious reflex can be broken up with more certainty.
EMOTIONAL SPONTANEOUS ABORTION
The emotional factors contributing to the “abortion habit” may be similar to those of the “accident habit” of certain self-destructive individuals. Thus the author and Freed postulated that the corticohypothalamic pathway can, through alternations in hormonal balance, alter the biochemical reactions in the rapidly growing placenta.32 Moreover, there is anatomic evidence that strong emotions can contract the uterine musculature and thus cause placental separation. Data of a positive nature which implicate the emotions consist of the evidence that the uteri of habitual aborters are hypersensitive to emotional stimuli, that there is a certain personality profile, that domesticated animals abort under unfavorable emotional environment, and that reports from a number of workers indicate favorable results following psychotherapy. There is also a considerable body of unclassified data which points to the role of emotions in abortion in patients who have miscarried during shock, fright or dangerous episodes.
More recently, proliferative changes in the placentas of spontaneous aborters, which resemble those of the collagen diseases, have been found secondary to mental stress. Gray and his associates noted that antibodies similar to those found in the collagen diseases can be detected in the serum of aborters.23 The fluctuations in 17-keto-steroids and 17-hydroxycorticoids secondary to stress, specific or nonspecific, may produce the pathologic changes in the placenta noted by Gray.
Platonov quotes Miloslavsky's recent systematic studies which showed that hypnosis could reduce uterine excitability, terminate bleeding and salvage a large number of fetuses.42 This substantiates Kroger and Freed's observations made in 1951.32
Nearly all investigators agree that the favorable results obtained in the treatment of this condition are chiefly due to the “mental rest” and the reassurance derived from the physician-patient relationship. The relationship of dreams and other unconscious factors in the production of threatened abortion and premature labor has been studied.8,9 Utilization of ideomotor finger signaling to elicit hidden psychodynamic factors responsible for these entities has yielded some very interesting correlations.8
HEARTBURN OF PREGNANCY
Heartburn of pregnancy has been termed a “monosymptomatic neurosis.” Here, too, the esophagus and the stomach are symbolically selected as the expression of the pregnant woman's inability to “swallow” or “stomach” the pregnancy because of deep-seated aversion to it. The esophageal spasm is noted in apprehensive women with lowered thresholds to sensory stimuli, especially in those who harbor latent guilt feelings over their overt or covert rejection of the child.
The therapy of heartburn of pregnancy due to psychogenic causes is directed toward the relief of the anxiety and the tension. As discussed in the section on nausea and vomiting, this may be accomplished by hypnotic exploration with a discussion and an explanation of the harmlessness of the symptom. In refractory cases, autohypnosis and glove anesthesia are beneficial.
LACTATION
Lactation often is influenced by emotional upsets.9 Conflicts can suppress lactogenic hormonal output via the hypothalamus and interfere with successful mammary function. Whether the hormonal dysfunction is due to a lack of love for the baby, or whether absence of motherly feelings is a product of a general psychosomatic immaturity, has yet to be established.
The literature relative to the influence of psychic factors on lactation has been reviewed.15 Mohr treated a patient who developed a sudden inability to nurse following psychic excitement.36Under hypnosis she was given a suggestion that on the way home she would feel milk flowing from her breasts. Within an hour she functioned normally, and there was no recurrence of her trouble. The French school of hypnotists—Liebeautl, Bernheim and others—made innumerable observations that the flow of milk could be stopped or increased by hypnosis. Heyer, in discussing the use of hypnosis during delivery, states: “Later it is very often possible to stimulate vigorously a decreasing flow of milk.”25 More recently, Goll has discussed the role of suggestion in the treatment of deficient lactation.21
The effective use of hypnosis has been demonstrated in stimulating milk production in 77 cases with over 95 per cent success.42 The technics involve the use of sensory-imagery conditioning and posthypnotic and autohypnotic suggestions. The results depend on the manner in which the suggestions are given. Usually, direct suggestions are not as effective as those that paint “mental pictures” of the milk flow from a full breast.
LATE TOXEMIAS OF PREGNANCY: PREECLAMPSIA AND ECLAMPSIA
The etiologic factors in the toxemias of pregnancy, especially preeclampsia and eclampsia, still remain inadequately explained. The author and Freed pointed out that the psyche plays some role in the operative mechanism of this disorder.32 However, it is acknowledged that this condition is largely a somatic one, from the clinical standpoint, with typical pathologic findings. One finds, however, in examining the reports made by students of this subject, the suggestion that psychological factors may be involved.49 Dieckmann states that preeclampsia and its complications are limited to civilized and cultured races, and that relatively primitive societies suffer from this condition only after contact with more “sophisticated” peoples.17 Pommerenke comments, “Dr. Dieckmann hints—with a voice that is perhaps too faint—that factors which some may regard as psychosomatic or sociologic may be operative in the etiology of eclampsia.”44
The author and Freed stated that the most likely possibilities to be considered in postulating a psychosomatic factor for this disorder are (1) placental ischemia, (2) stimulation of the posterior pituitary, and (3) imbalance or excess of certain adrenal corticosteroids.32 Thus psychosocial and other nonspecific factors potentially may lead to a disturbance of the cortical-hypothalamic-pituitary-adrenal axis, resulting in imbalance or excess of adrenal corticosteroids and/or a direct excitation or stimulation of the autonomic (pressor) nervous system, similarly mediated via a hypothalamic-pituitary-adrenal axis. Salerno recently supported these observations by clinical studies.48
Check and Le Cron state:
Hypnosis becomes a tool of life saving value in the presence of pyramiding fears due to prolonged labor, toxemia, hemorrhage, premature labor and overwhelming infection when medical attendants have become discouraged and frustrated with their failure to cure. With hypnosis we have a means to reestablish hope, diminish pain, stop fibrinolytic hemorrhage, reverse some of the effects of toxemia and improve resistance to infection.9
It has long been recognized that preeclamptics improve when hospitalized—environmental stresses are reduced. Hypno-relaxation can also raise the adaptive responses to stress. Autohypnosis is extremely helpful for recognizing anxiety-provoking tensions. Inducing the hypnotic state several times daily for relaxation, together with intelligent prenatal care, diet, sodium restriction and proper elimination, relieves many preeclamptics. Resistant individuals should be placed under medical management. However, hypnosis can be used prophylactically to decrease appetite and prevent weight gain. Naturally, the acute, fulminating phase of severe eclampsia cannot be helped by hypnosis.
DISCUSSION
As a result of the medical profession's interest in relaxation procedures for painless childbirth, a marked increase in the scientific applications of hypnosis has recently become apparent. It has been a belated but welcome recognition of the usefulness of hypnoanesthesia, either as an anesthetic agent or as an adjunct to chemoanesthesia.
Hypnoanesthesia for parturition is not a panacea, nor will it ever supplant chemoanesthetic agents, but its applications are growing daily and it is proving a powerful ally in alleviating other psychosomatic conditions in obstetrics.
Hypnosis is almost a specific for relief of the psychogenic component responsible for nausea and vomiting during early pregnancy. Hypnosis and/or strong suggestion are particularly valuable in the prevention of habitual abortion. Hypnosis can frequently diminish the strength and the frequency of the uterine contractions, and miscarriage can be prevented in properly selected patients if placental separation has not occurred. Experience indicates that placebos are as effective as vitamins and hormones in reducing the abortion rate; contradictory theories, the varied responses to edocrine therapy, and the frequent relapses with other types of therapy, all incriminate the psyche to some extent. Hypnosis can also be employed effectively in heartburn, to promote lactation, and to curb the “eating for two” syndrome often responsible for rapid weight gain and subsequent preeclampsia and toxemia.
The average physician can learn to induce hypnosis for anesthesia as readily as he learns to make an abdominal skin incision. However, to use this double-edged scalpel for intensive psychotherapy he must have the intuition, the knowledge and the judgment that characterize the skill of the surgeon who wields the scalpel.
It is hoped that the foregoing will stimulate more physicians to utilize hypnosis in childbirth and other obstetrical conditions. More active participation and public education in hypnotic methodology will help dispel misunderstanding and apprehension concerning hypnosis among the lay public. Since hypnosis is a very flexible agent, its utility in mitigating the pain of parturition could be broadened if it were used more often in conjunction with chemoanesthesia. Its use in this manner should have a salutary effect during pregnancy, labor, and delivery. Likewise, if the disadvantages and limitations enumerated above are taken into consideration, it will not be hailed as a panacea. Most physicians initially are enthusiastic about hypnotherapy in obstetrics, but disillusionment sets in after they find that it requires years of experience to use it intelligently and successfully.
REFERENCES
1. Abramson, M., and Heron, W.T.: An objective evaluation of hypnosis in obstetrics: preliminary report. Am. J. Obstet. Gynecol., 59:1069, 1950.
2. August, R.V.: Obstetric hypnoanesthesia. Am. J. Obstet. Gynecol., 79:1131, 1960.
3. _________: Hypnosis in Obstetrics. New York, McGraw-Hill, 1961.
4. _________: Hypnosis in Obstetrics: varying approaches. Am. J. Clin. Hypn., 8:47, 1965.
5. Ball, T.H.: Obstetrics in the Soviet Union. Trans. N.Y. Acad. Sci., 22:578, 1960.
6. Bronstein, I.: Psychoprophylactic Preparation for Painless Childbirth. New York, Grune & Stratton, 1958.
7. Carter, J.E.: Hypnotic induction of labor: a review and report of cases. Am. J. Clin. Hypn., 5:322, 1963.
8. Cheek, D.B.: Some newer understandings of dreams in relation to threatened abortion and premature labor. Pacific Med. Surg., 73:379, 1965.
9. Cheek, D.B., and Le Cron, L.: Clinical Hypnotherapy. New York, Grune & Stratton, 1968.
10. Chertok, L.: Psychoprophylaxis or obstetrical psychotherapy. Fortschr. Psychom. Med., 3:134, 1963.
11. Coulton, D.: Hypnosis in obstetrical delivery. Am. J. Clin. Hypn., 2:144, 1960.
12. _________: Prenatal and post-partum uses of hypnosis. Am. J. Clin. Hypn., 8:192, 1966.
13. Davenport-Slack, B.: A comparative evaluation of obstetrical hypnosis and antenatal childbirth training. Int. J. Clin. Exp. Hypn., 12:266, 1975.
14. Davidson, J.A.: Assessment of the value of hypnosis in pregnancy and labor. Br. Med. J., 2, 13:951, 1962.
15. DeLee, J.B.: Year Book of Obstetrics and Gynecology. Chicago, Year Book Medical Publishers, 1939, p. 164.
16. Dick-Read, G.: Childbirth Without Fear. New York, Harper, 1953.
17. Dieckmann , W.J.: Toxemias of Pregnancy. St. Louis, C.V. Mosby, 1941.
18. Dunbar, F.: Emotions and Bodily Changes. New York, Columbia University Press, 1946, pp. 311-315.
19. Fuchs, K., et al.: quoted by Crasilneck, H.B., and Hall, J.A.: Clinical Hypnosis. New York, Grune & Stratton, 1975, p. 115.
20. Furneaux, W.D., and Chapple, P.A.L.: Some objective and subjective characteristics of labor influenced by personality, and their modification by hypnosis and relaxation. Proc. Roy. Soc. Med., 57:261, 1964.
21. Goll, H.: Role of suggestion in hormonal therapy of hypogalactia. Munch. Med. Wochenschr., 89:55, 1942.
22. Goodrich, F.W.: Natural Childbirth. Englewood Cliffs, N.J., Prentice-Hall, 1956.
23. Gray, J.D.: The problem of spontaneous abortion. Am. J. Obstet. Gynecol., 74:111, 1957.
24. Hartman, W., and Rawlins, C.M.: Hypnosis in management of a case of abruptio placentae. Int. J. Clin. Exp. Hypn., 8:103, 1960.
25. Heyer, G.R.: (quoted by Dunbar) Hypnose und Hypnotherapie in die psychischen Heilmethoden. Hrsg. Von Karl Birnbaum. Leipzig, Georg Thieme, 1927, pp. 73-135.
26. Hilgard, E.R., and Hilgard, J.R.: Hypnosis in the Relief of Pain. Los Altos, Cal., William Kaufman, 1976.
27. Hoffman, G.L., Jr., and Kipenhauer, D.B.: Medical hypnosis and its use in obstetrics. Am. J. Med. Sci., 241:788, 1961.
28. Kroger, W.S.: The psychosomatic treatment of hyperemesis gravidarum by hypnosis. Am. J. Obstet. Gynecol., 51:544, 1946.
29. _________: Hypnoanesthesia in obstetrics. In Davis, C.H. (ed.): Gynecology and Obstetrics. Hagerstown, Md., Harper & Row, 1960, pp. 111-130.
30. _________: Natural childbirth. Med. Times, 80:152, 1952.
31. Kroger, W.S., and DeLee, S.T.: The use of the hypnoidal state as an amnesic analgesic and anesthetic agent in obstetrics. Am. J. Obstet. Gynecol., 46:655, 1943.
32. Kroger, W.S., and Freed, S.E.: Psychosomatic Gynecology: Including Problems of Obstetrical Care. Philadelphia, W.B. Saunders, 1951.
33. Lamaze, F.: Painless Childbirth. London, Burke, 1958.
34. Malyska, W., and Christensen, J.: Autohypnosis and the prenatal class. Am. J. Clin. Hypn., 9:188, 1967.
35. Mellgren, A.: Practical experiences with a modified hypnosis-delivery. Psychotherap. Psychosomat., 14:425, 1966.
36. Mohr, Fritz: (Quoted by Dunbar) Psychophysiche Behandlungsmethoden. Leipzig, Hirzel, 1925.
37. Mosconi, G.: II metodo ipnotico per la preparazione al parto. Minerva Med. Suppl., 3:2156, 1966.
38. Mosconi, G., and Starcich, B.: Preparacion del parto con hypnosis. Rev. Lat. Am. Hypn. Clin., 2:29, 1966.
39. Moya, F., and James, L.S.: Medical hypnosis for obstetrics. J.A.M.A., 174:80, 1960.
40. Oystragh, P.: The use of hypnosis in general and obstetrical practice. Med. J. Aust., 2:731, 1970.
41. Pascatto, R.D., and Mead, B.T.: The use of posthypnotic suggestions in obstetrics. Am. J. Clin. Hypn., 9:267, 1967.
42. Platonov, K.: The Word as a Physiological and Therapeutic Factor. Moscow, Foreign Languages Publishing House, 1955.
43. Platonov, M.V., et al.: quoted by Volgyesi, F.A.: The recent neuropsychiatric and biomorphologic justifications of hypnotherapeutic empiricism. Br. J. Med. Hypn., 2:6, 1950.
44. Pommerenke, W.T.: Discussion of Dieckmann, W.J., et al.: Etiology of eclampsia. Am. J. Obstet. Gynecol., 58:1014, 1949.
45. Reynolds, S.R.M.: Uterine contractility and cervical dilation. Proc. Roy. Soc. Med., 44:695, 1951.
46. Rock, N., et al.: Hypnosis with untrained, nonvolunteer patient in labor. Int. J. Clin. Exp. Hypn., 17:25, 1969.
47. Roig-Garcia, S.: The hypno-reflexogenous method: a new procedure in obstetrical psychoanalgesia. Am. J. Clin. Hypn., 6:15, 1961.
48. Salerno, L.J.: Psychophysiologic aspects of the toxemias of pregnancy. Am. J. Obstet. Gynecol., 76:1268, 1958.
49. Soichet, S.: Emotional factors in toxemia of pregnancy. Am. J. Obstet. Gynecol., 77:1065, 1959.
50. Spiegel, H.: Current perspectives on hypnosis in obstetrics. Act Psychotherap., 11:412, 1963.
51. Tom, K.S.: Hypnosis in obstetrics and gynecology. Obstet. Gynecol., 16:222, 1960.
52. Werner, W.E.: Hypnosis and acute uterine inversion. Am. J. Clin. Hypn., 7:229, 1965.
53. Winklestein, L.B.: Routine hypnosis for obstetrical delivery. Am. J. Obstet. Gynecol., 76:152, 1958.
54. Zuspan, F.P.: Hypnosis and the obstetrician-gynecologist. Obstet. Gynecol., 16:740, 1960.
ADDITIONAL READINGS
Chertok, L.: Psychosomatic Methods in Painless Childbirth. New York, Pergamon Press, 1959.
DeLee, S.T.: Hypnotism in pregnancy and labor. J.A.M.A., 159:750, 1955.
Kroger, S.W.: Hypnosis in obstetrics and gynecology. In Schneck, J.M. (ed.): Hypnosis in Modern Medicine. Springfield, Ill., Charles C Thomas, 1959.
Kroger, W.S., and Steinberg, J.: Childbirth With Hypnosis. New York, Doubleday, 1961.