1. Hypnosis Antenatal Training for Childbirth (HATCh): a randomised controlled trial A.M Cyna, C.A Crowther, J.S Robinson, M.I Andrew, G Antoniou, P Baghurst

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3. Hypnosis in pregnancy Previous systematic reviews suggested hypnosis – Decreased analgesia requirement during labour – Decreased augmentation during labour – Increases vaginal birth rates Included trials of above reviews: – small or poorly designed – mainly 1 st and 2 nd trimester

4. The Clinical Question Whether standardised group hypnosis training in late pregnancy reduced the need for analgesia during childbirth?

5. Structured Question Participants Women between 34 +0 and 39 +0 weeks gestation, singleton pregnancy cephalic presentation, planning a vaginal birth Intervention a)Group hypnosis sessions +Hypnotherapist-guided audio CDs b)Hypnotherapist-guided audio CDs only Comparison No additional antenatal intervention Outcomes Primary outcome: Use of pharmacological analgesia during labour Secondary outcomes: selected maternal and neonatal outcomes including use of augmentation, mode of delivery and neonatal Apgar scores

7. Graphical Appraisal GATE: Graphic Appraisal Tool for Epidemiological studies (Jackson, Evid Based Med 2006;11:35-38)

8. Background What is hypnosis? What are the potential risks and benefits of using hypnosis before and during childbirth? Compare the intervention in this study with other similar methods employing relaxation techniques in the antenatal and perinatal period.

9. Methods Critically appraise, do not simply accept on face value, the methods of this trial. For example: – Were the participants representative? – Was concealment sufficient? – What are the potential concerns of analysing participant data by a researcher unblinded to allocation?

10. Maternal analgesia during childbirth Data are numbers (%).RR (95% CI) = Risk Ratio (95% Cis), † Hypnosis versus control, § Audio CD versus control Hypnosis N = 154 CD only N = 143 Control N = 151 Total N = 448 RR (95%CI)P value Any Analgesia 125 (81.2)110 (76.9)115 (76.2)350 (78.1) † 1.07 (0.95 to 1.20) § 1.01 (0.89 to 1.15) 0.348 0.881 Analgesia except Entonox 98 (64.1)81 (56.6)85 (56.3)264 (59.1) † 1.14(0.95 to 1.37) § 1.01(0.82 to 1.23) 0.222 0.883 Epidural78 (51.0)63 (44.1)71 (47.0)212 (47.4) † 1.08 (0.86 to 1.36) § 0.94 (0.73 to 1.20) 0.490 0.611

11. Results What are the ethical and practical concerns of protocol violations? – Are there recognised methods to deal with these concerns? A higher proportion of women in the group hypnosis + CD group had history of depression. – How might this difference have affected the outcomes of this study?

12. Authors’ summary The antenatal group hypnosis in late pregnancy did not affect analgesia use during labour The methodology used in this study could provide a potentially useful template to study different methods of delivering a hypnosis intervention during childbirth.

13. Take home message In a single sentence, how would you describe the available evidence of antenatal hypnosis for pain relief in childbirth?

14. Suggested Reading Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev 442 2006(4):CD003521.