Description of the condition
Labour induction is a method to artificially stimulate uterine contractions in order to bring about childbirth. This method is a common obstetric intervention carried out to address a variety of complications, such as prolonged pregnancy, maternal illness or fetal death. In recent years the rate of labour induction has been rapidly increasing (Grobman 2007) and approximately 10% of 300,000 deliveries across 24 countries were induced, ranging from 1.4% in Niger to 35.5% in Sri Lanka (WHO 2011). Possible complications that lead to induction of labour include post-term pregnancy, prelabour rupture of membranes, hypertensive disorders (e.g. gestational hypertension, pre-eclampsia, or eclampsia), maternal medical complications (e.g. diabetes mellitus, abruptio placentae), fetal death, fetal growth restriction, suspected fetal macrosomia (large baby), chorioamnionitis (inflammation of the fetal membranes), multiple pregnancy, vaginal bleeding and other complications (ACOG 2009; WHO 2011). A related Cochrane review shows that a policy of labour induction compared with expectant management in postterm women is associated with fewer perinatal deaths and fewer caesarean sections (Gulmezoglu 2012). However, induced labour can also give rise to increased complications, such as bleeding, caesarean section, uterine hyperstimulation and rupture (WHO 2011). Although not advocated in current guidelines, induction of labour is sometimes elected by pregnant women, or for the convenience of clinicians (WHO 2011).
There are a variety of methods available for induction, including the following: pharmacological methods (e.g. administration of oxytocin, prostaglandins, hyaluronidase, corticosteroids, or oestrogen); mechanical methods (e.g. manually rupturing the amniotic membranes, membrane sweeping, laminaria tents or balloon catheters); and alternative medicine methods (e.g. acupuncture, hypnosis or non-invasive interventions). It can be complicated to balance the benefits and risks of each method. For instance, a recent systematic review suggested that prostaglandin E2 (PGE2) reduced the possibility of failure to deliver vaginally within 24 hours and vaginal misoprostol reduced the need for caesarean deliveries, but both interventions heightened the risk of uterine hyperstimulation (Mozurkewich 2011). Mechanical methods such as laminaria tents and balloon catheters reduced uterine hyperstimulation, but increased maternal and neonatal infectious complications (Mozurkewich 2011). Given these possible problems, complementary and alternative medicine (CAM) methods may provide a safer strategy. Hypnosis comes under this category. Up to now, it has been used mostly during active labour while its effectiveness in the induction of labour is largely unknown. The purpose of this protocol is to search out evidence of its use and benefits, if any, in induction.
Description of the intervention
Hypnosis is a technique that enhances concentration and increases suggestibility, while simultaneously decreasing sensory awareness (Burrows 2001).
According to the Society for Psychological Hypnosis, Division 30 of the American Psychological Association, a definition of hypnosis is as follows: "Hypnosis typically involves an introduction to the procedure during which the subject is told that suggestions for imaginative experiences will be presented. The hypnotic induction is an extended initial suggestion for using one's imagination, and may contain further elaborations of the introduction. A hypnotic procedure is used to encourage and evaluate responses to suggestions. When using hypnosis, one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought or behavior. Persons can also learn self-hypnosis, which is the act of administering hypnotic procedures on one's own. If the subject responds to hypnotic suggestions, it is generally inferred that hypnosis has been induced" (Green 2005). Hypnosis is practiced as hypnotherapy in psychotherapy and has applications in many other fields, including pain management (Montgomery 2000). The effect of hypnosis is thought to be mediated by the brain's anterior cingulate cortex (ACC) (Faymonville 2000), which is understood to be involved in processing negative emotional responses (Etkin 2011). A growing body of literature suggests that the ACC in the brain is critically involved in the processing of anxiety (Allman 2001; Shin 2010), meaning that hypnosis could play a role in minimising an anxious emotional response from this part of the brain. The method can be administered either by a hypnotherapist or through self-hypnosis, which women can learn to master during their pregnancy.
How the intervention might work
It is currently unknown how hypnosis works for induction of labour. However, a case report suggests that hypnosis might effect better relaxation of the cervix (Fist 1960). Also, hypnosis may enhance self-esteem (Torem 1992; Valente 1990), self-confidence, mastery and well-being (Simkin 2004), which can help to reduce anxiety in pregnant women. Maternal conditions of anxiety were significantly associated with the onset of labour in a comparative analysis of induced and spontaneous labours in the UK (Humphrey 2009). Recently, oxytocin has been considered to have anxiolytic or anxiety-relieving effects (Marazziti 2008; Netherton 2011), and a previous study showed a significant negative correlation between oxytocin and anxiety (Scantamburlo 2007). Thus it might be plausible to hypothesise that women who are extremely anxious about their impending labour are unable to produce the oxytocin necessary to stimulate contractions, and therefore, may find the relaxant properties of hypnosis beneficial. These findings hold promise for the application of hypnosis as a potentially effective technique to induce labour by decreasing stress in pregnant women.
Why it is important to do this review
Although there have been various reviews of CAM methods to manage pain during labour and childbirth (Cyna 2004; Jones 2012; Madden 2012), randomised controlled trials on hypnosis related to labour induction have not been fully evaluated. There have been some case reports or series on the effects of hypnosis on labour induction (Cyna 2003; Fist 1960; Rice 1961), but a lack of formal evidence. As induced labour is a standard obstetric intervention experienced by pregnant women when complications arise during pregnancy, it is important to find methods of labour induction that have minimal significant side effects. Hypnotic techniques have been used in obstetrics for over a 100 years (Werner 1982). A meta-analysis conducted by Cyna 2004 showed significantly less use of labour augmentation by oxytocin and an increased incidence of women delivering spontaneously in the hypnosis usage group. Reducing pharmaceutical interventions will prevent associated side effects. Few previous studies reported the costs of providing hypnosis in labour (Jones 2012). However, Cyna suggested that it was expected to be low in relation to the total costs of an episode of care, so it may be associated with substantial decreased costs to the healthcare system if effective (Cyna 2006).This review will set out a clear summary of the effectiveness of hypnosis for induction of labour and its potential significance to healthcare professionals and consumers who are seeking safe, alternative methods of labour induction.