Hypnobirthing Tips for Support People

Surfing around the internet today, I came across this interesting article about hypnobirthing, and some pros and cons of using it in labour (from http://dynamicdoula.blogspot.com.au/2012/02/hypnobirthing-for-birth-professionals.html).

I always think it is useful to get a balanced view, so I thought I would reproduce it here for you today…

HypnoBirthing for Birth Professionals: A seminar

Last weekend, I attended a seminar called Supporting the HypnoBirthing Mother and her Partner: A Workshop for Birth Professionals. You may know me as a scientist. As a researcher. As a critically-thinking repository of information. You probably do not know me as a HypnoBirther. Which I am totally not.

But this workshop left me with several ideas of how to use aspects of the method to help a mom and her partner feel calm and confident. These are using slow, deep breathing with some position change, and using positions in which the weight of the body is being held. Having confidence in visualization suggestions is also key in creating an atmosphere in which the body can relax.

But perhaps the biggest benefit of HypnoBirthing is that it gives the mother and her partner something to do throughout her entire labor.

What is HypnoBirthing?

HypnoBirthing, also called the Mongan Method (after its creator, Marie Mongan) uses hypnosis to enhance the trance-like altered state of active labor. That is my definition. Maybe yours is different.

In effect, HypnoBirthing is relaxation, breathing, and visualization.

Figure 1: Fear-tension-pain cycle, as per G. Dick-Read.

The crux of many popular modern childbirth philosophies is the “fear-tension-pain” phenomenon. When you are afraid or anxious, you tense up. When you tense up, you feel more pain. And when you feel more pain, it is scary. So if you can teach your body to relax, you can nip the cycle in the bud and things will hurt less. At the risk of using Comic Sans, I have illustrated the cycle on the right in Figure 1.

The idea is that the mother and her partner  begin preparing for a hypno-birth early — around the 20th week of pregnancy, much earlier than the typical childbirth education which is usually around 35 weeks — and the preparation includes childbirth education (that is the Birthing part) and guided meditation (that is the Hypno part) which is to be practiced at home in the months to come. The focus of the meditation is deep relaxation, the kind you get when you can no longer tell where you are or how long it has been, with a particular emphasis on breathing and visualizing the baby. And when the time comes to birth the baby, the mother has practiced relaxation so much that she can enter that state of deep relaxation easily and willingly. Add in some breathing and visualization techniques, and you have it.

What are these doctors doing here?

The instructor of this seminar for birth professionals, Rachel Yellin, a spunky gal with a huge mane of curly hair draping her cheeks, shoulders, and back, addressed the roomful of birth professionals. There were seventeen women and one man (a man!) in the room. Most were birth doulas, some were also yoga instructors and massage therapists. There were two obstetricians (the man was one) and a midwife; two grandmothers or soon-to-be grandmothers; and a few volunteers from the doula organization to which I belong. And there was me, researcher, marked by academic articles seeming to fall out of my ears.

I was as surprised (pleasantly) as Rachel to see obstetricians in the audience. It was surprising because douas are taught that obstetricians only come to deliver the baby. They do not participate in labor support. So what were these three clinicians (two OBs and a midwife) doing in the audience? It turned out that Jack was going to be supporting his brother and sister-in-law in the coming months, in the birth of their child, and he was terrified: having never been in a position of support, especially in early labor, and especially continuous, he was lost. As a birth professional, he did not want to take a full-blown childbirth education class, so he came here instead. Blair, the other obstetrician, and Alice, the midwife, wanted to learn how to help their hospital staff support HypnoBirthing couples. Learning more about the process of HypnoBirthing would help them not startle anybody and break the focused flow the mother had established for herself.

They really stole the show. Doulas had so many questions — about obstetric interventions, procedures at their hospital, and, most importantly, how doulas can help. I touched on this a bit in a previous blog post, Why I’ll Never Be a Nurse: some newer doulas have just enough education to be a nuisance, but not enough to be an asset to a birth team. I watched the collaboration unfold, and in the fifteen short minutes that the conversations proceeded I saw the doulas’ eyes light up, and some were taking notes. There really does need to be more training for doulas about hospital procedures, regulations, and liabilities. But I digress.

Do you want me to help you?

This is the first question any support person should ask any supportee. Do you want me to help you? Sometimes the answer is no. Sometimes the mother may want to feel miserable for a while, or to complain, or to find her own way. In that case, be present and wait.

But if the answer is yes, the support person will have some work to do.

HypnoBirthing is not a comfort measure. At least, not in the common sense of the words — which HypnoBirthers are encouraged not to use. The connotation of “comfort measures” is that something you can do will make the mother more comfortable. The idea is not to get more comfortable, but to dive deeper into the sensations. The idea is to relax more, enter a state of deeper relaxation: one that will allow the mother to open herself to the point of letting the sensations of labor sweep over her body.

Labor as an altered state of consciousness

Especially starting with active labor, when the mother can no longer ignore her body, and must concentrate her energy inwardly, the mother enters an altered state of consciousness. HypnoBirthing tries to harness this potential and works with it to help the mother enter this state of consciousness sooner and deeper than otherwise. The mother’s focus turns inward and she uses the techniques outlined above and below. Because the mother is in an altered state of consciousness, she is susceptible to suggestion. The altered state of consciousness can be considered meditation, and here is thus dubbed hypnosis. And because in this altered state, the mother is more keenly aware of suggestions, we call this altered state suggestion hypnosis. It is a relaxed altered state of consciousness.

Rachel said, “Remember that anything and everything that happens around a woman or to a woman during labor is a suggestion.” You look at the clock? Suggestion (too slow). You look at the read-out from the monitor? Suggestion (what’s wrong). The nurse does a vaginal exam? Suggestion (things go in, not out).

She said as labor support persons, we must be mindful of everything we do and the suggestions we give off, even unintentionally.

I could not agree more.

Three reasons for purposeful breathing

Rachel explained that there were three main reasons for purposeful breathing in labor, which is breathing while really concentrating on the breath going in and out of the body.

1.Oxygen. That is, you need it to survive. And so does the baby. Bringing oxygen to all the parts of the body that are doing the Big Work of Birthin’ is the main reason.

2.Sound. When the mother is concentrating on the sound the breath makes as it passes her throat and her nose (like yoga breathing), she cannot possibly concentrate on anything else. She cannot talk and (especially) complain, and she is forced to relax. It helps her enter and maintain that altered state HypnoBirthing is known for.

3.Bridge from Mother to Baby. Visualizing the baby and its uterine cocoon helps the mother’s body go through the steps of birthing a baby. And a continuous flow of oxygen to the baby is very important for the baby’s and the mother’s wellbeing in labor.

The good, the bad, and the skeptical

For me, there are two sides to every coin. Here are a few of those coins that hit a bell for me.

Relaxation in labor

The idea: Relaxing in labor helps labor move faster and hurt less.

The good: Certainly key! How many mothers exhaust themselves in early labor, pacing or cleaning? Rachel explained the importance of relaxation and breathing. She said to imagine a mother in labor as she is climbing up and down stairs or pacing the hallway to get things “moving,” as mothers in early labor are apt to be encouraged.

Figure 2: Slumped forward over baby

“Pain in labor comes from the baby pressing against a dehydrated uterus,” she said, meaning that the uterus lacks oxygenated blood. “Where is the oxygen? It is in the thighs, as she mounts each step; in the heart, beating faster, in the arms, holding on to the handrail.” Consider how much more blood her uterus would be getting if she were sitting, slumped over her baby (Figure 2); or lying on her side, curled around her baby; or on all fours, letting the weight of her body be held by a yoga ball. As an aside, I could not find a single freehand drawing program on my entire hard drive — my apologies to the woman pictured in Figure 2.

“The idea is,” said Rachel, “that all this movement and letting gravity help will bring on stronger and harder surges.” Oh, I forgot to mention. Contractions were renamed as surges because you want to give the idea that things are loosening, not tightening. Surges. Say it with me, and have some granola. It is good for you. “The harder surges may not be doing anything for the mother besides exhausting her.” Rachel’s implication was that the active mother’s uterus depleted of oxygen is the reason her surges are getting more intense, not that labor is actually moving faster.

Thus, the HypnoBirthing method relies on supported-body positions that do not require much exertion by the mother for two reasons:

1.Oxygen getting to the uterus, and

2.Mother staying very relaxed.

The skeptical: None, really, but I wanted to mention one thing: The supported-body positions must be changed on a regular basis. Because in the end, we do rely a little on gravity, and we need to help the baby traverse the narrow passage. As an active participant, the baby needs to tuck and turn and twist, and changing position frequently helps baby do just that.

Three types of breathing

The idea: Practicing three types of breathing (sleep, balloon, and birth breathing) helps the birth process.

1.Sleep breathing is a medium-length inhale and long, slow exhales lasting twice as long as the inhale: count in, in, in; and out six times.

2.Balloon breathing is similar to yoga breathing, using the sound in the back of the throat as a focal point in the meditation. Think about saying “haaaa” so that the whole room can hear you. Now do it with your mouth closed.

3.Birth breathing, or “breathing the baby down,” is a sequence of short, light grunts with which you expand the size of the stomach. They are like stomach thrusts using the air in your belly. This breath is supposed to be used in the second stage of labor.

The good: Sleep breathing promotes oxygen exchange through the body. Way to oxygenate that uterus, girl! Balloon breathing helps focus! And birth breathing helps the baby move into position gradually, come down the birth canal slowly, and be born gently with little danger to the perineum and little stress to the baby.

The skeptical: A few comments.

1.Early iterations of the Lamaze method tried to teach breathing. Remember the “hee-hee, ha-ha” breaths that movies always implement? That is Lamaze from the 70s. Researchers found that not only does Lamaze breathing not work as a labor support tool, but also the mother hyperventilates with these quick breaths. Good thing they got rid of that, right?

2.No animal has birthing breathing rituals in the wild. Have you ever seen a dog giving birth to puppies while yoga breathing?

3.When Rachel got to birth breathing and how it is meant to be performed in the second stage of labor (i.e., pushing), showing us how to do it, with her stomach bouncing rhythmically, we (that is, the class) imagined a woman in labor doing this and roared with laughter. “I have never seen a woman do this,” Alice (the midwife) said, “and I have seen a lot of HypnoBirthers.” When the body bears down, there will be no such breathing.

Remove the reference to pain

The idea: If you reframe the sensations a mother experiences, she will not be tempted to see it as pain. “Pain is when your body says something is wrong,” Rachel explained. “When you are in labor, there is nothing wrong. The sensations you are having are perfectly normal. They can be uncomfortable, sharp, stabbing, tightening, tingling — whatever!” She said that if you cut your finger, that hurts, and that is painful. Your body sends the signal to your brain so you can fix it. But in labor, there is nothing to fix.

The good: The woman in active labor is already in a deep state of relaxation, and an altered state of consciousness, so asking about pain and entertaining conversations about hurting are all very suggestive to her. Perhaps because pain is scary, and fear leads to tension, and so on. Refraining from bringing a mother’s attention to pain is probably a very good idea.

The skeptical: Alice, the midwife at the session, said she frequently sees HypnoBirthing patients come in and she cannot tell, at all, how far along in their labor they are because they are relaxed and smiling. She says it can be a real challenge, because they are the same patients that try to forego vaginal exams to determine labor progress. Rachel agreed and said the only way she can tell if a HypnoBirthing mom is pushing is she sees her stomach contract rhythmically.

So perhaps a strong benefit of HypnoBirthing is that nobody sees you in pain. When the mother is in a state of deep relaxation, nobody can tell how much discomfort she is feeling. That includes her care staff and her partner. If her partner is more relaxed (i.e., not worried about the sensations she is feeling), he or she can provide better care for her. Anxiety related to the mother’s pain level is a major fear factor for birth partners.

When HypnoBirthing women recall their experience, they do say things like “Oh, it hurt like hell,” or, as Rachel retold, “It felt like being stabbed by a fire poker.” So clearly, simply not thinking about pain does not make the pain go away. But it does alter other peoples’ impressions of the mother’s sensations because outwardly, she is not complaining.

The Benefits of Relaxation

A pamphlet about assisting women in labour using the Hypnobirthing techniques published in 2010 by Brandy Astwood, a HypnoBirthing childbirth educator, outlines the relevant research supporting HypnoBirthing and provides helpful suggestions for birth partners and nurses on how to help a woman that is using deep relaxation as her primary labor strategy. Her pamphlet collects results from several sources and is repeated here.

Fear, stress and tension have long been known to be associated with increased levels of pain as reported by patients. Grantly Dick-Read, MD, described the “Fear-Tension-Pain Syndrome” in the 1920s, and since that time obstetrical care providers have noted that education and stress management strategies have been effective in decreasing the level of pain reported by women in labor.

Hypnosis has been used effectively in the management of pain for over a century, but fell out of favor with the advent of safer, more effective analgesia/anesthesia. Over the years, several studies have been undertaken to research the efficacy of hypnosis in childbirth. A meta-analysis of these studies, “Hypnosis for Pain Relief in Labour and Childbirth: A Systematic Review,” appeared in the British Journal of Anesthesia in 2004. The article states

This report represents the most comprehensive review of the literature to date on the use of hypnosis for analgesia during childbirth. The meta-analysis shows that hypnosis reduces analgesia requirements in labour. Apart from the analgesia and anaesthetic effects possible in receptive subjects, there are three other possible reasons why analgesic consumption during childbirth might be reduced when using hypnosis. First, teaching self-hypnosis facilitates patient autonomy and a sense of control. Secondly, the majority of parturients are likely to be able to use hypnosis for relaxation, thus reducing apprehension that in turn may reduce analgesic requirements. Finally, the possible reduction in the need for pharmacological augmentation of labour when hypnosis is used for childbirth, may minimize the incidence of uterine hyperstimulation and the need for epidural analgesia.1

Obstetrical patients using self-hypnosis have been shown to have lower scores for pain associated with childbirth, shorter duration of both first and second stage labor, increased number of spontaneous births, decreased use of analgesia, anesthesia and labor augmentation and infants with higher average Apgar scores.

HypnoBirthing® teaches women to relax quickly and completely with uterine contractions, and to use visualization to help facilitate cervical effacement, dilation, and fetal descent. Women and their birthing companions are taught that fear and tension lead to increased levels of catecholamines, which ultimately causes increased pain during labor. The positive effects of visualization are thought to be similar to those achieved by athletes using mental imagery to prepare for competition. Rather than using multiple types of breathing and imagery to distract the laboring woman from her discomfort, HypnoBirthing® allows a woman to become deeply focused upon the birthing process.

When in labor, a woman using this method is not asleep or unconscious, and is receptive to suggestions made by her birthing companion and others. For this reason, references to pain, medications and procedures are best kept to a minimum. Women using HypnoBirthing® will ask for analgesia or anesthesia if they need it.

HypnoBirthing® encourages the laboring woman to allow passive descent in second stage and to “breathe the baby down” with release of air as she “feels the urge.” The HypnoBirthing method discourages Valsalva pushing, and beginning to push before the woman has the involuntary urge to do so. Recent studies have shown few risks and some benefits in allowing the mother to “labor down” in second stage, allowing passive descent, as opposed to “pushing” as soon as cervical dilation is complete. With passive descent, there are fewer fetal heart rate decelerations and less fetal acidosis. Maternal benefits include a shorter period of “pushing” and less fatigue. Unless specifically instructed otherwise, women begin bearing down spontaneously when the fetal presenting part is well down in the birth canal; they will generally wait until the contraction peaks and then give a series of “mini-pushes” with air release.

HypnoBirthing® stresses that the goal is a gentle and safe birth for the baby. Staying relaxed and focused upon her baby and the birthing process enables the birthing woman to remain calm and more comfortable. Her companion(s) will help her to maintain this calm focus with music, dim lights, soft touch, and speaking words of encouragement. They will also help her to remain well nourished and hydrated and assist her in moving about. The companions will advocate for the mother and baby if interventions are suggested and help the woman to make informed decisions.

We find that, no matter what turn the labor and birth may take, most couples are very satisfied with their birthing experience. Because they are calm and relaxed, they will feel empowered to make good decisions if interventions become advisable.

—  Brandy Astwood’s pamphlet, 2010 [doc]

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