Guided Imagery:A Best Practice forPregnancy and Childbirthby Belleruth Naparstek

GUIDED IMAGERY:MORE THAN JUST RELAXATION

Guided imagery is a made-to-order intervention for theunique demands of pregnancy and childbirth. A deliber-ate kind of directed daydreaming, narrated by a soothingvoice over relaxing music, it produces a calm state offocused, energized readiness that reduces discomfort whileoffering emotional support and a feeling of confidencein the body's inherent wisdom.

More than just relaxing, imagery can set the stagefor productive, confident labor; it can focus breathing andencourage a powerful alliance with uterine contractions;it can increase a sense of gratitude for the body and themiracle of childbirth; and it can enhance a feeling ofconnection with the growing baby.

While delivering all these benefits, imagery is nonethe-less easy to use and extremely non-demanding in nature.All that is required is the ability to listen. And becauseit can be delivered through a simple audio recording— a CD or download — it requires no special expertise,practice, or discipline from either the listener or her carepartners, beyond an ability to press "play." For this reason,it has been rightly called "the lazy man's meditation" or"do-it-yourself hypnosis."

ESTABLISHED EFFICACY

Imagery has been quietly but consistently producing im-pressive outcomes in health and medicine over the past15 years. It was found to reduce anxiety and depression(McKinney et al. 1997), lower blood pressure (Hermann2002), reduce cholesterol (Bennett and Carroll 1990) andlipid peroxides (Schneider et al. 1998), speed up heal-ing from cuts (Ginandes et al. 2003), fractures (Ginandesand Rosenthal 1999), and burns (Fratianne et al. 2001),reduce blood loss (Dreher 1998) and length of hospitalstay in surgery patients (Halpin et al. 2002), enhanceshort-term immune function (Gruzeiier 2002), reducepain from arthritis (Sharpe et al. 2001) and fibromyalgia(Whiting 2001), increase comfort during all manners ofmedical procedures (Montgomery et al. 2002), lowerHemoglobinAlc in diabetics (Surwit et al. 2002), improvemotor deficits in stroke patients (Page et al. 2001), reducefear in young children undergoing MRls (Smart 1997)and needle sticks (Albert 2000), cut down bingeing andpurging in people with bulimia (Esplen et al. 1998),improve success rates in infertile couples (Domar et al.2000), accelerate weight loss (Johnson and Karkut 1996),and improve concentration in developmentally disabledadults (Poretta dn Surburg 1995). A recent meta-analysis

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ABSTRACT

Guided imagery is an excellentintervention for the uniquedemands of pregnancy and

childbirth, delivering a ready-made, complementary therapyfor childbirth professionals to

include in their tool kit.This article explores the ways

that imagery takes the listenerbeyond simple relaxation to set

the stage for productive, confidentlabor; enhance appreciation forthe miracle of the body; focus

breathing; and, reduce painand promote a greater sense of

connectedness with the baby.It describes recent research

showing efficacy, offers samplesof its evocative language,and provides practitioner

tips for optimal use.

showed that hypnosis and imagery reduced pain andthe need for pain medication in laboring women (Cyna,McAuliffe, and Andrew 2004).

WHY IT WORKS

This simple, subtle practice packs a powerful punch be-cause of the way it can skip around cognition and sendhealing messages straight into the whole being, by wayof primitive, sensory, and emotion-based channels in thebrain and nervous system. Imagery travels primarily viaright brain sensing — perceiving, feeling, apprehending,and motor reactivity, rather than through left brain think-ing — judging, analyzing, and deciding. Because of this,and the way that pregnancy and childbirth heighten thefunctioning of primitive, survival struaures of the brain, it isan ideal intervention for pregnancy, labor, and delivery.

It is fast, powerful, costs little or nothing, and getsmore and more effective with continued use. Its end userneedn't be smart, rich, well-educated, young, strong, normentally healthy to reap its considerable benefits. Listen-ers can be bone-tired, disgusted, depressed, exasperated,frightened, terrified, disinterested, resistant, distracted, ormentally disabled, and it will still capture their atten-tion long enough to bestow its beneficent blessings onthem. continued on page 5

GUIDED IMAGERY from page 4

The calming voice tones, pacing, music, and evoca-tive images help to create an altered state, where pain isreduced and capacity for focus is increased. This is whyimagery is such a preferred technique for athletes fac-ing the high performance demands of competition — asituation very comparable to labor. It mobilizes everypart of the person — body, mind, and spirit — behindthe goal of doing everything possible to create the bestpossible outcome. For women in childbirth, there is theadded advantage of the natural flood of trance-inducinghormones that cascade through the body, intensifyingthe altered state and potentiating the imagery experienceeven further,

SAMPLES OF IMAGERY'SEVOCATIVE LANGUAGE

FOR PREGNANCY AND LABOR

Guided imagery can be as simple as imagining a favoritetime or place, in all its sensory beauty — its sights, sounds,smells, and feel — as vi/ell as the emotional responsesproduced within. This can be a sufficiently pleasant dis-traction, occupying just enough cognitive space in themind, to turn attention away from the discomforts ofpregnancy or the intense rigors of childbirth, to createan inner haven of peace, calm, and safety.

But guided imagery that is specifically geared to preg-nancy can achieve much more than mere relaxation andsimple distraction from pain. Early on in the pregnancy,it can promote delight in the genius of the body and itsdazzling ability to support life; it can create a sense ofconnection to the mystery unfolding within;

And you may have noticed... a gent/e preoccupaf/on witbthe soft dark chambers of your interior... where sweet se-crets of new life lay folded... tucked away, safe, and cozy...your whole hody smi/ing... as ft senses how each beat ofyour heart... surges nourishment and strength... suffusingthis new being with everything it needs,.. (Excerpted fromNaparstek 2000d).

Imagery can reduce isolation and fear, and initiate thelistener into the powerful new phase of life she is about toenter — motherhood — reminding her that this is a paththat has been taken by countless women before her. Itcan help her mark the importance of entering this phaseof life, and honor it — and in doing so, honor herself.

Pkdsed to be joining the company of ail the women whohave come before you... and all the women who wiil comeafter you... and feeling their same sense of wonder andgratitude... (Excerpted from Naparstek 2000a).

Imagery can reframe the discomfort of random con-tractions, reminding the listener of how these fit into thelarger picture and serve the greater goal:

All the while, uterine muscles rehearsing ar)d toning... ivarm-ing up with occasional contractions... so that when the timeis right... it can move into capable aaion with efficiency andease... (Excerpted from Naparstek 2000a).

It can also help her better tolerate the discomfortsof bloating, fatigue, changing body image, and shiftingmoods...

And you can be confident in the knowledge that even thediscomfort you might feel from time to time... comes fromthe purposeful activity of your body... from new hormonelevels, increased blood flow, and ail the new requirementsof muscle, skin, and bone... (Excerpted from Naparstek2000a).

...while supporting the communication of a silentdialogue between mother and baby:

feeling the soft weight of your hands on your body... thewarmth from your hands soaking into layers of tissue... deeperand deeper... sending a greeting and blessing inward... (Ex-cerpted from Naparstek 2000a).

Imagery can invoke the proteaion of the ancestors— grandparents and greatg rand pa rents — to contributea powerful sense of the greater continuity of life andpurpose:

And sensing the presence of smiling ancestors... leaningover and softly whispering this child's name.., transferringto this baby their highest hopes and deepest intentions...to pick up their banner,., and carry the best of what theystood for... (Excerpted from Naparstek 2000a).

It can add to the delight and excitement of this uniqueadventure:

And you know... with your whole being... in the deepestpart of your heart... that this new life that you carry insideof you is a gift... like no other... a precious link in thegreat chain... necessary and perfect... designed to havethe world a better place for having been in it... (Excerptedfrom Naparstek 2000a).

Guided imagery that focuses on the birthing processcan augment v̂ /hat has been learned in childbirth classes,and support the help a doctor, nurse, midwife, doula, orfamily coach offers during labor. In cases where no helpis available, it can be a lifeline. Imagery can remind alaboring woman that her body knows how to do this:

And you know... that your body already knows how to dothis... is a trustworthy ally... perfectly organized to go intoaaion... every cell committed to the fullest... With a built-inintelligence, distilled and honed through the ages... (Excerptedfrom Naparstek 2000b).

continued on page 6

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GUIDED IMAGERY from page 5

Imagery can remind the laboring woman that she isnot alone, but in the spiritual company of generationsand generations of women:

...by centur/es of women who have come before you...doing as you are doing now... So in a sense... they tooare ell behind you now... strong and stead/,., patient andknowing... smiling, as they remember their own journey...into the power and mystery of motherhood... (Excerptedfrom Naparstek 2000h).

It can engender confidence and a sense of readiness,like an athlete who has been training all along:

And so now... as your contraaions begin to settle into a regularpattern... you know that you too have been rehearsing andtoning... that you can feel ready and strong... (Excerptedfrom Naparstek 2000b).

And it can focus breathing into the contractions:

Sending the warm energy of the breath... all around andthrough the bowed muscle of the uterus... and letting thepower of the breath go right into the heart of the contrac-tion... and help it soften and release... (Excerpted fromNaparstek 2000b).

Imagery can encourage endurance and patience withreminders that progress is being made:

And you know... that with each contraction... important workis being done., that while you are breathing in and out...fully and deeply... with your mind focused and steady...your body is ingeniously carrying out its plan... movingforward in a steady, reliable progression... (Excerpted fromNaparstek 2000b).

It can support confidence in the capable caring pro-fessionals and helpers in the delivery room:

...looking after you with great competence and care... withcapable, respectful hands... along with partners and fam-ily members with loving hearts... who share your awe forthis miraculous process... so ordinary and yet so magical...(Excerpted from Naparstek 2000b).

Imagery can remind the laboring woman that theexasperation of the transition phase is an indicator thatthe end is in sight:

And you know... that at the time wher] you feel the mostdiscomfort... the most irritation... impatience... that this isthe time when the most work is being done... that the endis in sight... the final stretch is coming... (Excerpted fromNaparstek 2000b).

And imagery can support the work of pushing;

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And now, // you can feel it, your body wants to bear downwith each powerful contraction... every fiber of your beingimpelled... to bear down and push out this baby... witha commitment and force like no other... because it is theonly thing your body wants to do... and you can let yourcaregivers coach you... helping you holdback... with pantingbreaths... and telling you when to push... (Excerpted fromNaparstek 2000b).

Once the baby arrives, imagery can promote bonding,whether immediate or gradual, in the mother:

...a fee//ng of relief... and accomplishment... and gratitude...and the beginnings of a tenderness like no other... that youmay feel right away... or that may gradually overtake you...over the next dap and iveeh... unt;7 one day you realize...that your capacity to feel love... is beyond anything youever imagined... that your heart has been opened widerthan you ever thought possible... (Excerpted from Naparstek2000b).

GENERAL TIPS AND POINTERS

Here are some general pointers to keep in mind whenencouraging people to try guided imagery for pregnancyand labor:

• Almost anyone can use this tool.• Skill and efficiency increase cumulatively with prac-

tice. People are able to benefit in a faster, deeperway with repeated use.

• Imagery works best in a permissive, relaxed, unforcedatmosphere. There is no one way to "do it right."

• Effective imagery uses all the senses, not just thevisual sense, and especially it uses the kinestheticor feeling sense. Only half of the population isstrongly visual.

• Poetic language, filled with symbols, similes, andmetaphors, is especially effective at capturing atten-tion, driving the altered state, and making a deepimpression on mind, body, and spirit.

• As important as the choice of words is, it will neverbe as important as the quality of the voice, the in-tention behind it, and the music that accompaniesit.

• The narrator's voice should be natural, low, deepin the body, and the pacing should be a naturaloutcome of his or her relaxed breathing.

• Imagery is generally more powerful in a group set-ting, mainly due to the contagious nature of thealtered state, making a childbirth education groupor support group an ideal place to experience it.

• Music, when properly chosen, will increase thepotency of imagery. People intuitively know whatmusic is right for them. A small percentage of peopleprefer no music at all, especially if they know a lotabout music or are extremely sensitive to/criticalof it. continued on page 7

GUIDED IMAGERY from page 6

• Imagery that elicits emotion is generally more ef-fective than imagery thai does not. Respondingmxh emotion is a good sign that the imagery isvi/orking in a deep way.

• Imagery that deliberately elicits feelings of loveand gratitude has special ability to reduce fearand center the listener.

• It's best to avoid the imperative verb form, so thatinadvertently "bossy" language doesn't marshalunnecessary resistance.

• The listener does not have to be a "believer" in or-der for imagery to work. Positive expectancy helps,but even a skeptical willingness to give it a try issufficient.

• Touch may be the most powerful accompaniment toimagery, both to help with relaxation and to increasethe kinesthetic power of the images. Imagery whencombined with therapeutic massage, energy work,or other kinesthetic modalities is very potent, andmore than the sum of its parts.

• When the listener uses the same postural cues,gestures, or hand-positioning with each imagingexperience, an "anchor" is created that conditionsan immediate relaxation response when needed,particularly during labor.

• Imagery that creates feelings of lovingness andgratitude elevates serotonin levels enough to re-duce pain.

• Imagery by its very nature distracts and refocusesattention, and thus reduces pain.

• Because of hormonal activity, laboring womenare in a natural trance state, which potentiates theimagery experience even further.

• Even during sleep, people benefit from repeatedlistening, as demonstrated in outcomes with diabeticand anesthetized surgery patients.

• It is commonplace to "space out" or lose track ofa guided imagery narrative. This does not meanthat it is being listened to incorrectly — this oftencomes with the territory,

• People frequently tear up, get a runny nose, cough,yawn, feel heaviness in their limbs, get tinglingsensations along the top of their scalp or in theirhands and feet, or experience minor, involuntarymuscle movements. These are normal responses.

• Other indicators of a strong response to imagery areunusual stillness, increased coloring in the face, anda smoothing out of lines and wrinkles. The voicedrops deeper and lower, and speech is slower andmore relaxed.

CONCLUSION

Guided imagery is a best practice, which can accomplisha great deal to support the pregnant or laboring woman,taking her beyond simple relaxation, to support a moreconfident, meaningful, and positive pregnancy and laborexperience, while demanding very little by way of training

or effort in return. It does not compete in any way withother methods, and collaborates well with other practicesin the caregiver's tool kit.

References

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Cyna, A. M., G, L. McAuliffe. and M. I. Andrew. 2004. Hypnosis forpain relief in labor and childbirth: A systematic review. British journalof Anaesthesia 93 (4): 505-511.

Domar, A. D., D. Clapp, E. A. Slawsby, J. Dusek, B. Kesset, and M, Freiz-inger. 2000. Impact of group psychological interventions on pregnancyrates in infertile women. Fertility end Sterility 73 (4): 805-811.

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• Psychoffierapist, author, and guided imagery pioneer Beiieruth Napantekis the creator of the Health Journeys guided imagery audio series, includingMeditations for a Healthy Pregnancy and Successful Childbirth, Her latestbook, Invisible Heroes: Survivors of Trauma and How They Heal, wasreleased in 2006. Her guided imagery is distributed by Aetna U.S. Healthcare,the U.S. Veteran's Administration, Tfie American Red Cross, Kaiser Permanente,United Health Care. Oxford Health Plans, and Blue Shield of Californid, andis involved in 22 clinical trials.

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