DOI: 10.1111/1471-0528.

12320 General obstetrics

www.bjog.org

Hypnosis Antenatal Training for Childbirth:

a randomised controlled trial
AM Cyna,a,b CA Crowther,c,d JS Robinson,c MI Andrew,a G Antoniou,e P Baghurste
a
Department of Women’s Anaesthesia, Women’s & Children’s Hospital, North Adelaide, Australia b Acute Care Medicine, University of
Adelaide, Adelaide, Australia c Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia d The Liggins Institute, University of
Auckland, Auckland, New Zealand e Public Health Research Unit, Women’s and Children’s Hospital, North Adelaide, Australia
Correspondence: Dr AM Cyna, Department of Women’s Anaesthesia, Women’s & Children’s Hospital, 72 King William Road, Adelaide,
SA 5006, Australia. Email allan.cyna@health.sa.gov.au

Accepted 19 April 2013. Published Online 3 July 2013.

Objective To determine the use of pharmacologic analgesia during
childbirth when antenatal hypnosis is added to standard care.
Design Randomised controlled clinical trial, conducted from
December 2005 to December 2010.
Setting The largest tertiary referral centre for maternity care in
South Australia.
Population A cohort of 448 women at >34 weeks of gestation,
with a singleton pregnancy and cephalic presentation, planning a
vaginal birth. Exclusions were: the need for an interpreter; pre-
existing pain; psychiatric illness; younger than 18 years; and
previous experience of hypnosis for childbirth.
Methods All participants received usual care. The group of
women termed Hypnosis + CD (hypnotherapist guided) were
offered three antenatal live hypnosis sessions plus each session’s
corresponding audio CD for further practise, as well as a final
fourth CD to listen to during labour. The group of women
termed CD only (nurse administered) were played the same
antenatal hypnosis CDs as group 1, but did not receive live
hypnosis training. The control group participants were given no
additional intervention or CDs.
Main outcome measure Use of pharmacological analgesia during
labour and childbirth.
Results No difference in the use of pharmacological analgesia
during labour and childbirth was found comparing
hypnosis + CD with control (81.2 versus 76.2%; relative risk, RR
1.07; 95% confidence interval, 95% CI 0.95–1.20), or comparing
CD only with control (76.9 versus 76.2%, RR 1.01, 95% CI 0.89–
1.15).
Conclusions Antenatal group hypnosis using the Hypnosis
Antenatal Training for Childbirth (HATCh) intervention in late
pregnancy does not reduce the use of pharmacological analgesia
during labour and childbirth.
Keywords Analgesia, childbirth, communication, hypnosis,
labour, psychological responses.

Please cite this paper as: Cyna A, Crowther C, Robinson J, Andrew M, Antoniou G, Baghurst P. Hypnosis Antenatal Training for Childbirth: a randomised
controlled trial. BJOG 2013;120:1248–1259.

negative myths associated with hypnosis have led to a

Introduction
Hypnosis is difficult to define,1 but appears to be a day-
dream-like, conscious state of focused attention that can
result in a reduced awareness of external stimuli, and an
increased response to suggestion.2,3 Suggestions are verbal
or non-verbal communications that lead to apparent non-
volitional changes in patient perception or behaviour, and
are pivotal in eliciting hypnotic responses.4,5
Pain relief during childbirth has been a primary target of
clinical hypnosis for more than a century.6 Anaesthesia and
clinical hypnosis have had a long association.7 The intro-
duction of chemical analgesia in the 19th century and
decline in its use.8 However, since the 1950s there has been
renewed interest after hypnosis was formally recognised by
the British Medical Association (BMA) Working Party as
an effective clinical tool.9 More recently, positron emission
tomography or functional magnetic resonance imaging
have shown the consistent finding of anterior cingulate
modulation when hypnosis is used to induce analgesia.10–12
Perceptions of the increased medicalisation of childbirth
have led many women to look for alternative means of
relieving pain during labour.13,14 Hypnosis, despite being
used for some remarkable cases of painless surgery,15,16 has
not been considered to be a reliable method of labour

1248 ª 2013 RCOG


analgesia.17 Systematic reviews of randomised controlled
trials (RCTs) investigating the effects of hypnosis during
childbirth have suggested that hypnosis decreases analgesia
requirements during labour, decreases the use of oxytocic
labour augmentation, and increases the incidence of vaginal
birth.14,18,19 This evidence has come from small or poorly
designed trials,20–24 which were inadequate to confirm these
apparent benefits.25,26 Antenatal hypnosis training of
women in the first and second trimester of pregnancy was
found to reduce analgesia use during childbirth, and fur-
ther study in late pregnancy was advocated.24 We investi-
gated whether standardised group hypnosis training in late
pregnancy reduced analgesia requirements during child-
birth.25
Methods
The Hypnosis Antenatal Training for Childbirth (HATCh)
trial was an RCT using a three-arm parallel group design,
with a 1:1:1 ratio. It was conducted in the largest tertiary
referral centre for maternity care in South Australia, between
December 2005 and December 2010. Women between 34+0
and 39+0 weeks of gestation, who were planning a vaginal
birth, were not in active labour, and were carrying a single-
ton, viable fetus of vertex presentation were eligible for inclu-
sion. Exclusion criteria were: previous hypnosis preparation
for childbirth; poor understanding of English, requiring a
translator; current enrolment in another pregnancy trial in
which analgesia requirements were an outcome measure;
active psychological or psychiatric problems; and severe
intellectual disability. Women with previous hypnosis child-
birth training or with pre-existing pain were also excluded.
Following trial registration (ACTRN012605000018617, 18
July 2005; NCT00282204, 24 January 2006), and approval
from the Women’s and Children’s Hospital Human
Research Ethics Committee in 2004 and subsequently
extended by the Child Youth and Women’s Health Service
(CYWHS) Human Research Ethics Committee (REC 1600/
12/09), informed written patient consent was obtained
from eligible women agreeing to participate. After baseline
demographic testing was completed, study participants
were stratified for parity and randomised in (unspecified)
blocks of 15 by a computer random number generator.
Allocation concealment was assured by using a computer
database assignment to one of three groups, which was
only revealed after patient identifiers had been entered.
Participants in the hypnosis + CD group received ante-
natal hypnosis training from a doctor qualified in hypnosis
and were given a CD on hypnosis after each session to
supplement the intervention. Participants in the CD-only
group received the HATCh intervention by listening to the
relevant CD for each session, administered by a nurse with
no training in hypnotherapy. After each session,
ª 2013 RCOG
The Hypnosis Antenatal Training for Childbirth trial
participants in the hypnosis + CD and CD-only groups
were provided with a CD on hypnosis designed for each
session. The HATCh intervention was administered in a
group setting, with attendance over three consecutive
weekly sessions, and participants were asked to practise on
a daily basis at home using the relevant CD. At the third
antenatal session, participants allocated to the hypno-
sis + CD and CD-only groups were provided with CDs 3
and 4 and asked to use the fourth CD in labour. Control
group participants continued with their usual preparation
for childbirth, such as antenatal classes and clinic appoint-
ments, with no additional intervention.25 Participants
unable to attend an allocated session in person were
contacted by telephone, and the relevant CD was posted
for them to listen to prior to their next session. All partici-
pants received usual care and follow-up, regardless of
group allocation. Participants assigned to hypnosis groups
commenced hypnosis training as near as possible to
37 weeks of gestation. Treatment allocations were
concealed from the treating obstetricians, anaesthetists,
midwives, and personnel who were collecting the data. Our
primary outcome, the use of pharmacological analgesia
during labour and childbirth was defined as using one or
more analgesia techniques, such as: inhaled nitrous oxide
in oxygen (EntonoxTM); a parenteral opioid such as intra-
muscular Pethidine; and/or epidural analgesia, such as
0.2% Ropivacaine with fentanyl, 2 mg/ml. The attending
midwife documented all analgesia use and mode of delivery
on the birth register. A researcher, blinded to treatment
allocation, managed data collection from medical and nurs-
ing records on the ward from postnatal questionnaires after
the birth, and then at 6 weeks follow-up, as detailed previ-
ously.25 In addition, At 6 months follow–up we asked
women about treatment for depression since the birth.
Development of the structured intervention
delivered by CD on hypnosis
The HATCh intervention was based on published scripts of
suggestions, by experts in the administration of hypnosis
for childbirth,27,28 combined with our own clinical experi-
ence. HATCh intervention scripts were used to produce
three CDs that mirrored our hypnosis preparation for
childbirth, with each CD lasting between 21 and 32 min-
utes.29,30 A fourth CD lasting 18 minutes was also devel-
oped for use during labour and childbirth.29 Women in the
hypnosis + CD group were guided in to a state of hypnosis
using the preferred induction method of the hypnothera-
pist: usually an eye fixation technique or Spiegel.31,32
Power calculation
An audit of 100 consecutive mothers birthing at our insti-
tution in May 2004 showed an incidence of using one or
more pharmacological interventions of 80%. In order to
1249
 Cyna et al.
show a clinically relevant difference of 20% in the number
of women requiring pharmacological analgesia, we used a
two-tailed calculation (NQUERY ADVISOR 5.0; Statistical Solu-
tions Ltd., Cork, Ireland). A study power of 80% would
require each group to contain 135 women to detect this
difference at the 0.05 level. We planned to recruit 150
women per group, as we estimated that 10% of participants
would deliver prior to receiving their allocated treatment.
Following baseline demographic data collection, which
included the administration of the Edinburgh Postnatal
Depression Scale (EPDS),33 Spielberger State–Trait Anxiety
Inventory,34 and Creative Imagination Scale (CIS),35 trial
participants were informed of where and when to attend
their allocated sessions.
Baseline measures
The Spielberger State–Trait Anxiety Inventory involves
asking participants to score 20 statements on a four-point
Likert scale, indicating the frequency with which they
have felt a certain emotion over the previous 7 days.
Scores > 44 have been classed as indicating a state of high
anxiety.36,37
The EPDS consists of ten statements that evaluate how
an individual has felt over the previous 7 days.33 The EPDS
has been recommended for routine use to identify women
at risk for postnatal depression,38 and a score > 12 is
widely used to indicate a probable depressive disorder.39
Study participants were left undisturbed to measure their
baseline hypnotisability by listening to a CD of the CIS.35
This scale is self-appraising, and the maximum score is 40.
The CIS scale CD was made in-house from published
scripts,35 and contained ten scenarios that encourage test
subjects to use their imagination to create suggested effects,
such as arm heaviness, age regression, and time distortion.
Each scenario is ranked by the participant on a five-point
Likert scale to score their experience: 0, 0%; 1, 25%; 2,
50%; 3, 75%; 4, 90%.
Data management/analyses
After completing nearly 2 years of recruitment, we became
aware that some women, who were ineligible for participa-
tion, had been inadvertently randomised, outside our eligi-
bility criteria, prior to 34 weeks of gestation. We therefore
continued to recruit women until our initial planned sam-
ple size of eligible women had been reached. Only women
who met all eligibility criteria for inclusion were analysed
(Figure 1). Participant data were analysed by a researcher
who was not blinded to allocation, in accordance and with
the ‘intention to treat’ (ITT) principle, and with compre-
hensive pre-planned subgroup analyses.25 Initial analyses
examined baseline characteristics of all randomised partici-
pants, and any chance differences in this baseline data
between treatment groups were adjusted for in subsequent
1250
analyses, and reported upon if there were any significant
differences to unadjusted data.
Preplanned subgroup analyses of primary outcomes were
performed for women regarding: induced versus spontane-
ous labour; attendance at all three sessions, whether each
session CD was used at least once; women’s hypnotisability,
as measured by the CIS; women’s beliefs of the efficacy of
hypnosis prior to labour; women’s expectations of requir-
ing an epidural; women’s expectations of having a normal
spontaneous birth; and previous use of yoga. Descriptive
statistics are presented as mean, standard deviation (SD)
for normally distributed data, median and interquartile
(IQR) range for skewed data, and proportions for dichoto-
mous outcomes. Likelihood ratio chi-square statistics and
relative risks (RRs) with 95% confidence intervals (95%
CIs) or odds ratios (ORs) have been used. Differences at
the level of P < 0.05 were considered to be significant. For
ease of interpretation, relative risks were estimated wher-
ever possible using binomial models with a log-link. In
subgroup analyses where models with the log link failed to
converge, odds ratios were estimated using a binomial
model with a logit link.
Results
The eligibility of 776 women for trial entry was assessed
between December 2005 and July 2009, and 448 women
were found to be eligible and were included in the study
(Figure 1). At 6 weeks postpartum, 400 women (89.3%)
returned questionnaires with data suitable for analyses. Our
baseline data shows that the randomisation with stratifica-
tion for parity produced comparable groups (Table 1).
Compliance with treatment allocation and
scheduling
The attendance of HATCh trial participants according to
their allocated group and self-reported compliance with
listening to the CD on at least one occasion is shown
according to their allocated group (Table S1). Less than
50% of women allocated to an intervention attended all
three allocated hypnosis sessions, and even fewer attended
the CD sessions. Hypnosis training undertaken outside the
trial was reported by 17 HATCh trial participants (3.9%):
two allocated to the hypnosis group (1.3%), seven allocated
to the CD only group (5.0%), and eight allocated to the
control group (5.6%). Trial participants were no less likely
to seek additional training if they were allocated to the
hypnosis group (RR 0.24, 95% CI 0.05–1.12, P = 0.07),
when compared with controls.
Analgesia outcomes
There was no difference in our primary outcome – the use
of pharmacological analgesia during childbirth – between
ª 2013 RCOG
 The Hypnosis Antenatal Training for Childbirth trial

Women ineligible (not fulfilling the

eligibility criteria) n = 140
Women assessed for eligibility
n = 776 Potentially eligible women
declining to participate n = 50

Randomisation of women
n = 586 Nulliparous = 448 Protocol violations
Multiparous = 138 Ineligible women randomised
1. Active labour n = 1
2. Gestation < 34 weeks, n = 137
Nulliparous = 99
Multiparous = 38

Randomisation of eligible participants

n = 448 nulliparous = 348 multiparous = 100

Hypnosis + CD n = 154 CD only n = 143 Control n = 151

Nulliparous = 124 Nulliparous = 110 Nulliparous = 114
Multiparous = 30 Multiparous = 33 Multiparous = 37

Analysed at birth n = 154 Analysed at birth n = 143 Analysed at birth n = 151

Excluded from analysis n = 0 Excluded from analysis n = 0 Excluded from analyses n = 0

Analysed at 6 weeks n = 134 Analysed at 6weeks n = 133 Analysed at 6weeks n = 133

Not analysed (unreturned Not analysed (unreturned Not analysed (unreturned
questionnaires) n = 20 questionnaires) n = 10 questionnaires) n = 18

Figure 1. HATCh trial flow.

groups when comparing hypnosis 125/154 (81.2%) with
control 115/151 (76.2%) (RR 1.07, 95% CI 0.95–1.20), and
when comparing CD only 110/143 (76.9%) with control
(RR 1.01, 95% CI 0.89–1.15). There were also no differ-
ences found with respect to the use of epidural analgesia or
other pharmacological analgesia (Table 2).
Maternal secondary outcomes
No differences were found in key secondary outcomes with
respect to: mode of delivery; use of augmentation of
labour; and other birth outcomes (Table 3), including
median length of labour (IQR) of 8 (7.3), 8.3 (7.9), and
7.4 (6.7) hours for women in the hypnosis + CD, CD only,
and control groups, respectively. Similarly, there was no
difference in the number of days women stayed in hospital
postpartum: 4 (2) days for each group. There was an
increased use of prostaglandins for induction in women
allocated to the hypnosis group when compared with con-
trols, but no significant differences between groups on
admission to the high dependency unit (HDU), incidence
of episiotomy, need for blood transfusion, or number of
days in hospital after the birth (Table 3). There was also
no difference in the incidence of exclusive breastfeeding at
hospital discharge, although more women in the control
group reported that they were exclusively breast feeding at
6 weeks when compared with those in the hypnosis group
(P < 0.05).
There were no differences between groups with regard to
the mother perceiving that she had received adequate pain
relief, or of the birth being better than expected or a posi-
tive experience (Table 4). There were also no differences
between groups regarding, perceived maternal pain inten-
sity, satisfaction with the birth experience, sense of control
during labour, ability to cope, or satisfaction with the
childbirth experience (Table S2).
At the 6–week assessments, there were no differences
between the groups in EPDS, Spielberger, zero to 10
numerical pain scores during childbirth, or satisfaction
with the birth experience (Table S2). There were no differ-
ences in the incidence of maternal re-admission to hospital
or problems related to the use of hypnosis between groups
(Table S3). Those women exposed to the hypnosis or CD

ª 2013 RCOG 1251

 Cyna et al.

Table 1. Maternal baseline demographic data and psychological testing of HATCh participants at recruitment

Baseline demographic data Hypnosis + CD CD only Control Total

n = 154 n = 143 n = 151 n = 448

Age* 30.5, 5.1 31.4, 4.4 31.2, 4.7 31.0, 4.7

Nulliparity 124 (80.5) 110 (76.9) 114 (75.5) 348 (77.7)
BMI** 22.9, 5.5 22.9, 4.4 22, 4.2 22.7, 4.7
(n = 151) (n = 140) (n = 150) (n = 441)
Gestational age (weeks)** 35.1, 1.4 35.3, 1.6 35.0, 1.3 35.1, 1.6
Tertiary education 86 (55.8) 84 (58.7) 83 (55.0) 253 (56.5)
Australian born 112 (72.7) 107 (74.8) 111 (73.5) 330 (73.7)
Previous caesarean section 7 (4.6) 5 (3.5) 6 (4.0) 18 (4.0)
Previous epidural 20 (13.0) 20 (14.0) 18 (11.9) 58 (13.0)
History of depression*** 43 (27.9) 26 (18.2) 27 (17.9) 96 (21.4)
Complementary therapy in pregnancy 86 (55.8) 75 (52.5) 83 (55.0) 244 (54.5)
Yoga 65 (42.2) 68 (47.6) 70 (46.4) 203 (45.3)
EPDS 6, 6 5, 6 4.5, 6 (n = 150) 5, 5 (n = 447)
EPDS > 12**** 15 (9.7) 9 (6.3) 6 (4.0) 30 (6.7)
Spielberger state 30.0, 13 (n = 153) 29, 13 30, 11 30, 12 (n = 447)
Spielberger trait 32.5, 12 31, 12 30, 10 31, 12
CIS 23, 11 (n = 137) 23, 10.5 (n = 124) 23, 11 (n = 129) 23, 11 (n = 390)

BMI, body mass index; HATCh, Hypnosis Antenatal Training for Childbirth; RR, relative risk; SD, standard deviation. Numbers of women (%) are
shown, unless otherwise stated.
Hypnotisability, as measured by the CIS, anxiety, as measured by the Spielberger State–Trait Anxiety Inventory, and depression, as measured by
the EPDS, according to allocated group.
*Mean, SD.
**Median, interquartile range.
***Hypnosis versus control: RR = 1.56; P = 0.040.
****Hypnosis versus control: RR = 2.44; P = 0.058, borderline statistical significance.

Table 2. Maternal analgesia outcomes during childbirth, according to group allocation

Analgesia use during childbirth Hypnosis n = 154 CD only n = 143 Control n = 151 Total n = 448 RR (95% CI) P

Any analgesia 125 (81.2) 110 (76.9) 115 (76.2) 350 (78.1) 1.07 (0.95–1.20)* 0.348
1.01 (0.89–1.15)** 0.881
Analgesia, except Entonox 98 (64.1) 81 (56.6) 85 (56.3) 264 (59.1) 1.14 (0.95–1.37)* 0.222
1.01 (0.82–1.23)** 0.883
Epidural labour analgesia 78 (51.0) 63 (44.1) 71 (47.0) 212 (47.4) 1.08 (0.86–1.36)* 0.490
0.94 (0.73–1.20)** 0.611

Data are shown as numbers (%).

*Hypnosis versus control.
**CD versus control.

intervention were more likely to state that they would use
hypnosis in future pregnancies (Table S3).
Of the planned subgroup analyses, there were no dif-
ferences between groups in any of the key outcomes.
Analgesia use during labour and childbirth subgrouped
by parity, induction, CIS score, yoga, previous experience
of clinical hypnosis, and compliance with the interven-
tion showed no difference between groups (Table 5).
Women who used yoga and who were allocated to
receive hypnosis used less analgesia than women who did
not use yoga and were allocated to receive hypnosis 70.8
versus 88.8% (P = 0.005). This difference was also seen
in the CD-only group, 66.2 versus 86.7% (P = 0.003),
but was not seen in the women in the control group
who used or did not use yoga (Table 5), 74.3% versus
77.8% (P = 0.616).

1252 ª 2013 RCOG

 The Hypnosis Antenatal Training for Childbirth trial

Table 3. Key maternal secondary outcomes according to group allocation

Key outcomes Hypnosis + CD CD only Control Total n = 448 RR (95% CI) P

n = 154 n = 143 n = 151

Oxytocin 57 (37.3) 53 (37.1) 56 (37.1) 166 (37.1) 1.00 (0.75–1.35)* 0.976

1.00 (0.74–1.35)** 0.997
Spontaneous vaginal birth 85 (55.2) 84 (58.7) 92 (60.9) 261 (58.3) 0.91 (0.75–1.10)* 0.311
0.96 (0.80–1.16)** 0.703
Induced labour 63 (40.9) 43 (30.1) 47 (31.1) 153 (34.2) 1.31 (0.97–1.78)* 0.078
0.97 (0.69–1.36)** 0.844
Induction with prostaglandins 55 (35.7) 32 (22.4) 35 (23.2) 122 (27.2) 1.54 (1.08–2.21)* 0.018
0.97 (0.63–1.47)** 0.870
Augmentation 66 (42.9) 66 (46.2) 66 (43.7) 198 (44.2) 0.98 (0.76–1.27)* 0.881
1.06 (0.82–1.36)** 0.673
Caesarean section 38 (24.7) 25 (17.5) 29 (19.2) 92 (20.5) 1.29 (0.84–1.97)* 0.837
0.91 (0.56–1.48)** 0.561
Forceps/vacuum 31 (21.3) 34 (23.8) 30 (19.9) 95 (21.2) 1.01 (0.65–1.59)* 0.954
1.20 (0.78–1.85)** 0.418
Episiotomy 24 (15.6) 25 (17.5) 26 (17.2) 75 (16.7) 0.91 (0.55–1.50)* 0.700
1.02 (0.62–1.67)** 0.952
Intact perineum 94 (61.4) 71 (49.7) 91 (60.3) 256 (57.3) 1.02 (0.85–1.22)* 0.834
0.82 (0.67–1.02)** 0.070
PPH 24 (15.6) 22 (15.4) 14 (9.3) 60 (13.4) 1.68 (0.91–3.12)* 0.101
1.66 (0.88–3.12)** 0.115
Blood transfusion 4 (2.6) 7 (4.9) 1 (0.7) 12 (2.7) 3.92 (0.44–34.69)* 0.219
7.39 (0.92–59.33)** 0.060
Admission to HDU/ICU 3 (2.0) 7 (4.9) 2 (1.3) 12 (2.7) 1.47 (0.25–8.68)* 0.670
3.70 (0.78–17.50)** 0.099
Readmission to hospital 11 (8.2) 8 (6.0) 7 (5.3) 26 (6.5) 1.56 (0.62–3.90)* 0.342
n = 134 n = 133 n = 133 n = 400 1.14 (0.43–3.06)** 0.791
Neonatal Apgar score < 7 at 5 minutes 1 (0.7) 1 (0.7) 2 (1.3) 4 (0.9) 0.49 (0.05–5.32)* 0.555
0.53 (0.05–5.72)** 0.597
Baby admitted to SCBU 53 (34.4) 45 (31.5) 51 (33.8) 149 (33.3) 1.02 (0.75–1.39)* 0.906
0.93 (0.67–1.30)** 0.674

Data are as shown as numbers of women (%); HDU/ICU, high-dependency unit/intensive care unit; PPH, postpartum haemorrhage.
*Hypnosis versus control.
**CD versus control.

Table 4. Secondary outcomes: maternal perceptions of the birth experience

Key outcomes Hypnosis + CD CD only Control Total RR (95% CI) P

n = 154 n = 143 n = 151 n = 448

Received adequate pain relief 112 (82.4) 92 (70.2) 99 (77.3) 303 (76.7) 1.07 (0.94–1.20)* 0.313
n = 136 n = 131 n = 128 n = 395 0.91 (0.79–1.05)** 0.194
Birth a positive experience 108 (72.5) 105 (75.5) 118 (81.9) 331 (76.6) 0.89 (0.78–1.00)* 0.055
n = 149 n = 139 n = 144 n = 432 0.92 (0.82–1.04)** 0.190
Birth better than expected 59 (41.0) 44 (32.1) 46 (32.2) 149 (35.1) 1.27 (0.94–1.73)* 0.124
n = 144 n = 137 n = 143 n = 424 1.00 (0.71–1.40)** 0.993

Data are as shown as numbers of women (%).

*Hypnosis versus control.
**CD versus control.

ª 2013 RCOG 1253

 Cyna et al.

Table 5. Analgesia use during labour and childbirth subgrouped by parity, induction, CIS score, yoga, previous experience of clinical hypnosis,
attendance at all three sessions, and all hypnosis and CDs used at least once, versus some/all CDs not listened to (with the controls excluded from
the last two analyses)

Subgroup Hypnosis + CD CD only Control Total OR (95%CI)

n = 154 n = 143 n = 151 n = 448

Parity N 105/124 (84.7) 90/110 (81.8) 93/114 (81.6) 288/348 (82.8) 1.25 (0.63–2.46)*
1.02 (0.52–2.00)**
M 20/30 (66.7) 20/33 (66.6) 22/37 (59.5) 62/100 (62.0) 1.36 (0.50–3.72)*
1.05 (0.40–2.73)**
Induction/spontaneous I 59/63 (93.7) 39/43 (90.7) 45/47 (95.7) 143/153 (93.5) –
–
S 60/85 (70.6) 68/97 (70.1) 67/101 (66.3) 195/283 (68.9) 1.22 (0.65–2.27)*
1.19 (0.65–2.17)**
CIS score <23 50/60 (83.3) 48/60 (80.0) 45/63 (71.4) 143/183 (78.1) 2.00 (0.84–4.78)*
1.60 (0.69–3.69)**
≥23 63/77 (81.8) 47/64 (73.4) 52/66 (78.8) 162/207 (78.3) 1.21 (0.53–2.77)*
0.74 (0.33–1.67)**
Yoga Y 46/65 (70.8) 45/68 (66.2) 52/70 (74.3) 143/203 (70.4) 0.84 (0.39–1.79)*
0.68 (0.33–1.41)**
N 79/89 (88.8) 65/75 (86.7) 63/81 (77.8) 207/245 (84.5) 2.26 (0.97–5.23)*
1.86 (0.80–4.33)**
Previous experience of clinical hypnosis Y 8/12 (66.7) 3/5 (60.0) 9/13 (69.2) 20/30 (66.7) –
–
N 117/142 (82.4) 107/138 (77.5) 106/138 (76.8) 330/418 (79.0) 1.39 (0.79–2.44)*
1.18 (0.67–2.08)**
Three hypnosis sessions Y 55/68 (80.9) 44/57 (77.2) 99/125 (79.2) 1.25 (0.53–2.97)*
N 70/86 (81.4) 66/86 (76.7) 136/172 (79.1) 1.33 (0.63–2.77)**
All CDs listened to Y 45/58 (77.6) 45/66 (68.2) 90/124 (72.6) 1.62 (0.72–3.62)*
N 68/79 (86.1) 59/70 (84.3) 127/149 (85.2) 1.15 (0.47–2.85)***

Data are shown as numbers (%); –, too few numbers to perform OR analyses.
*Hypnosis versus control.
**CD versus control.
***Hypnosis versus CD.

Approximately 15% of babies had meconium-stained
liquor across the groups, and one-third of babies were
admitted to the special care baby unit (SCBU). However,
there were no differences in the incidence of meconium-
stained liquor, babies with an Apgar score < 7 at 5 min-
utes, and admissions to the SCBU, between the three
groups (Table 3).
Nearly 50% of women in the intervention groups
believed that hypnosis was helpful during the birth. No
differences were reported with respect to incidence of baby
re-admissions to hospital and whether the baby was settled
or not (Table S4).
Discussion
Main findings
The key finding of the HATCh trial is that antenatal group
hypnosis training in the third trimester, using the particu-
lar three-session regimen of this study, did not influence
the use of pharmacological analgesia during labour and
childbirth. In addition, mode of delivery and the use of
oxytocics were similarly unaffected. An unexpected finding
of our study was that women allocated to the hypno-
sis + CD group had an increased incidence of having an
induction of labour and prostaglandin administration.
Hypnosis has been used as an intervention to induce
labour.40 Whether this was a chance occurrence or not, any
effect of hypnosis in reducing analgesia may have been
masked by more painful, induced labour. Apart from this
outcome, there was a surprising lack of statistically signifi-
cant findings between groups. Of the planned subgroup
analyses there were no differences between groups in any
of the key outcomes; however, it was interesting to note
that women who used yoga and who were allocated to
receive hypnosis used less analgesia than women who did
not use yoga and were allocated to receive hypnosis. Like
hypnosis, yoga also involves the use of imagery, positive
suggestion and ‘trance-like’ states. The familiarity with

1254 ª 2013 RCOG


these states may have primed this subgroup of women to
learn the hypnosis techniques taught in this study over a
shorter period of time.
Strengths and weaknesses
The HATCh trial was a comprehensive, high-quality,
randomised trial that was designed to assess the efficacy of
a short, three-session, standardised hypnosis intervention in
late pregnancy. Strengths included: the health significance
of the issue; the inclusion of both nulliparous and multipa-
rous women; the comprehensive, clinically meaningful
nature of the outcomes chosen; the support of preliminary
studies and meta-analyses; and the investigators’ experience
with the intervention. A rigorous experimental design was
used and similar groups at baseline were achieved by using
balanced randomisation, stratified for parity. Prior to this
trial, only one study had a comparable sample size but was
much less rigorous in its methodology, and made no
attempt to standardise the intervention.24 All other previ-
ous hypnosis studies in this setting have recruited <100
participants. The use of the CDs was an innovative feature
of the study, with which investigators attempted to stan-
dardise the suggestions used during the intervention and
facilitate replication should the findings had shown efficacy.
The psychological measures for depression and anxiety
have been previously validated in this setting. The CIS used
for hypnotisability assessments were standardised by using
an identical CD of the scale and response sheets adminis-
tered on an individual basis to trial participants at trial
entry. This had the advantage of avoiding a formal
hypnotic induction, which minimised the possibility of
contaminating our control group with an experience of
hypnosis. The planned primary outcome of reduced phar-
macological analgesic intervention was a reasonable objec-
tive, as it was absolute and relatively easy to measure.
The HATCh trial had several limitations. Firstly, there
were a number of post-randomisation exclusions resulting
from an inadvertent error during the eligibility assessment
of gestation at trial entry. We therefore continued recruit-
ing until our initial planned sample size had been reached,
a strategy consistent with a suggested approach for the
management of inadvertently recruiting ineligible subjects
after randomisation.41 Only a minority of women actually
attended all three sessions and listened to all four CDs;
however, our subgroup analyses do not support poor com-
pliance as a reason for the lack of efficacy of the hypnosis
intervention. Although every attempt was made to conceal
treatment allocations from obstetricians, anaesthetists, mid-
wives, and the personnel collecting data, double-blinding a
hypnosis intervention is unlikely if women are not fully
informed, as in earlier studies.21–23
About 80% of all women in our institution received
pharmaceutical analgesia. A high proportion of HATCh
ª 2013 RCOG
The Hypnosis Antenatal Training for Childbirth trial
trial participants had a post-school qualification (Table 1).
These highly educated women may not be representative of
the pregnant population of other studies where hypnosis
training has been found to be effective.
Previous studies, where a beneficial effect has been
shown, have used more than three antenatal sessions,21,23,24
and administered the intervention at an earlier gestation
than we did in our study.23,24 Interestingly, a previous
randomised trial where hypnosis failed to reduce analgesia
requirements during labour also had a design that involved
beginning the antenatal hypnosis training late in the third
trimester.20 The ready availability of epidural analgesia may
also have influenced our study findings. If epidural analge-
sia is not available on demand, as appeared the case in
previous studies with positive findings, the likelihood that
hypnosis will reduce analgesia use may be increased. Many
medical interventions in our institution are protocol
driven. In this regard, there may have been rates of inter-
vention, such as caesarean section or epidural use during
labour and childbirth, in this tertiary setting that were not
amenable to change by the hypnosis intervention. In
another study investigating continuous support in labour
provided to a low-risk population, in general greater bene-
fits were found when epidural analgesia was not routinely
available, including: decreased caesarean section rates and
increased spontaneous vaginal birth.42 Future areas of
research might include: a comparison of antenatal hypnosis
training inside and outside a tertiary referral centre, where
an ‘on demand’ epidural service is unavailable; the use of
different methods to teach hypnosis preparation for labour
analgesia; and using yoga as part of the hypnosis training
regimen.
Interpretation
The HATCh trial represents the best-quality evidence to
date investigating the effects of hypnosis training on anal-
gesia use during childbirth.43,44 The negative findings may
convince many that it is ineffective in the clinical environ-
ment we have explored, irrespective of timing or tech-
niques, and it may not be worthwhile pursuing lengthier
and less feasible approaches in the hope of gaining benefit
in a tertiary referral setting with an ‘on demand’ epidural
service. Although our findings show that the HATCh inter-
vention in late pregnancy cannot be recommended, the rig-
orous methodology used provides a potentially useful
template for the conduct of future investigations assessing
the effectiveness of different ways of administering a
hypnosis intervention for pain relief and other beneficial
outcomes in childbirth.
Disclosure of interests
All authors have completed the Unified Competing Inter-
est form at http://www.icmje.org/coi_disclosure.pdf (avail-
1255
 Cyna et al.
able on request from the corresponding author), and
declare: support from the University of Adelaide; Austra-
lian Society of Anaesthetists; the Women’s and Children’s
Foundation; and NH&MRC project grant 453446. This
paper represents, in part, the PhD thesis http://digi-
tal.library.adelaide.edu.au/dspace/bitstream/2440/69216/1/
02whole.pdf. Dr Allan Cyna is a co-author of the Cochra-
ne review that includes, in part, data from the HATCh
trial reported in this article. There were no other relation-
ships or activities that could appear to have influenced
the submitted work.
Contribution to authorship
AMC, MIA, JSR, and CAC have contributed to the over-
all concept and design. AMC and MIA helped design and
co-ordinate the final content of the hypnotherapeutic
interventions. PB and GA organised the acquisition of
the data and the analysis of the data. AMC, JSR, CAC,
PB, and GA were involved in drafting the article. Each
author has participated sufficiently in the work to take
public responsibility for appropriate portions of the con-
tent. AMC was responsible for acquiring funding, super-
vised the research, and takes responsibility for it. All
authors have read and approved the final version of the
article.
Details of ethics approval
Trial registration: ACTRN012605000018617, 18 July 2005;
NCT00282204, 24 January 2006. Initial ethics approval was
obtained on 13 December 2004 from the Women’s & Chil-
dren’s Hospital Research Ethics Committee (approval num-
ber 1600/6/2007), and this approval was extended from the
Child Youth and Women’s Health Service (CYWHS)
Human Research Ethics Committee on 13 December 2006
(approval number REC 1600/12/09).
Funding
This study received funding from: the University of Adela-
ide; the Australian Society of Anaesthetists; the Women’s
and Children’s Foundation; and NH&MRC project grant
453446.
Acknowledgements
We thank, Drs Celia Whittle, Graham G Wicks, and Pat-
rick McCarthy for their advice on the hypnosis interven-
tion. Dr Graham Wicks gave advice regarding
hypnotisability testing and Professor Deborah Turnbull
advised on the psychological aspects of the study. We
also acknowledge research assistance from Denise Healy,
Karen Belchambers, Carmel Mercer, Louise Goodchild,
Meredith Krieg, Ros Lontis, Deni Haines, Pat Ashwood,
Andrea Deussen and administrative assistance form Cindy-
Lee Brown.
1256
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Number of sessions attended by trial partici-
pants and self-reported compliance with listening to audio
CD on hypnosis, according to allocated group.
Table S2. Maternal psychological and perceived child-
birth pain outcomes at 6 weeks postpartum follow-up.
Table S3. Maternal outcomes at 6 weeks postpartum.
Table S4. Neonatal outcomes at 6 week assessment post-
partum.
Data S1. Powerpoint slides summarising the study. &
References
1 Yapko M. Trancework: An Introduction to the Practice of Clinical
Hypnosis, 4th edn. New York, NY: Routlidge, Taylor Francis Group,
2012.
2 Greenleaf E. Defining hypnosis during hypnotherapy. Int J Clin Exp
Hypn 1974;22:120–30.
3 Gamsa A. Hypnotic analgesia. In: Melzack R, Wall PD, editors.
Handbook of Pain Management. London: Churchill Livingstone;
2003. pp 521–31.
4 Woody E, Sadler P. Some polite applause for the 2003 APA Division
30 definition of hypnosis. Am J Clin Hypn 2005;48:99–106.
5 Hammond DC. Formulating hypnotic and post-hypnotic suggestions.
In: Hammond DC, editor. Handbook of Hypnotic Suggestions and
Metaphors. Illinois: Am Soc Clin Hyp, 1990:11–44.
6 Gravitz MA. Early uses of hypnosis as surgical anesthesia. Am J Clin
Hypn 1988;30:201–8.
7 Fuge C. Bedford square. A connection with mesmerism. Anaesthesia
1986;41:726–30.
8 Snow JS, editor. Blessed days of Anaesthesia. Oxford, UK: Oxford
University Press, 2008.
9 BMA Working Party. Medical use of hypnotism: BMA Subcommittee
to Council, Supplementary report of BMJ, App X, 1955:190–93.
10 Faymonville ME, Roediger L, Del Fiore G, Delgueldre C, Phillips C,
Lamy M, et al. Increased cerebral functional connectivity underlying
the antinociceptive effects of hypnosis. Brain Res Cogn Brain Res
2003;17:255–62.
11 Faymonville ME, Laureys S, Degueldre C, DelFiore G, Luxen A,
Franck G, et al. Neural mechanisms of antinociceptive effects of
hypnosis. Anesthesiology 2000;92:1257–67.
12 Rainville P, Duncan GH, Price DD, Carrier B, Bushnell MC. Pain
affect encoded in human anterior cingulate but not somatosensory
cortex. Science 1997;277:968–71.
13 Johanson R, Newburn M, MacFarlane A. Has the medicalisation of
childbirth gone too far? BMJ 2002;324:892–5.
14 Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and
alternative therapies for pain management in labour. Cochrane Database
Syst Rev 2006; Issue 2. Art. No.: CD003521. doi: 10.1002/14651858.
15 Kroger WS, De Lee ST. Use of hypno-anesthesia for cesarean section
and hysterectomy. JAMA 1957;163:442–4.
16 Wong L, Cyna AM, Matthews G. Rapid hypnosis as an anaesthesia
adjunct for evacuation of postpartum vulval haematoma. Aust N Z J
Obstet Gynaecol 2011;51:265–7.
17 Minnich M. Childbirth preparation and nonpharmacologic analgesia.
In: Chestnut DH, editor. Obstetric Anesthesia: Principles and
Practice, 3rd edn. St. Louis: Mosby; 2004. pp 302–10.
ª 2013 RCOG
 The Hypnosis Antenatal Training for Childbirth trial

18 Huntley AL, Coon JT. Complementary and alternative medicine for
labor pain: a systematic review. Am J Obstet Gynecol 2004;191:36–
44.
19 Cyna A, McAuliffe G, Andrew M. Hypnosis for pain relief in labour
and childbirth: a systematic review. Br J Anaesth 2004;93:505–11.
20 Freeman RM, Macaulay AJ, Eve L, Chamberlain GVP. Randomised
trial of self hypnosis for analgesia in labour. BMJ 1986;292:657–8.
21 Harmon TM, Hynan MT, Tyre TE. Improved obstetric outcomes using
hypnotic analgesia and skill mastery combined with childbirth
education. J Consult Clin Psychol 1990;58:525–30.
22 Rock N, Shipley T, Campbell C. Hypnosis with untrained
nonvolunteer patients in labor. Int J Clin Exp Hypn 1969;17:25–36.
23 Martin AA, Schauble PG, Rai SH, Curry RW. The effects of hypnosis
on the labor processes and birth outcomes of pregnant adolescents.
J Fam Pract 2001;50:441–3.
24 Mehl-Madrona LE. Hypnosis to facilitate uncomplicated birth. Am J
Clin Hyp 2004;46:299–312.
25 Cyna AM, Andrew MI, Robinson JS, Crowther CA, Baghurst P,
Turnbull D, et al. Hypnosis Antenatal Training for Childbirth
(HATCh): a randomised controlled trial [NCT00282204]. BMC
Pregnancy Childbirth 2006;6:5. http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC1450315/ (Accessed 1 March 2013).
26 Cyna AM, Andrew MI, McAuliffe GL. Antenatal self-hypnosis for
labour and childbirth: a pilot study. Anaesth Int Care 2006;34:
464–9.
27 Waxman D. Management of antenatal hypnotic training. In:
Hammond DC, editor. Handbook of Hypnotic Suggestions and
Metaphors. London: WW Norton, 1990: NY, 279-81.
28 McCarthy P. Hypnosis in obstetrics. Aus J Clin Exp Hypn
1998;26:35–42.
29 Cyna AM, Andrew MI, Whittle C. Hypnosis Antenatal Training for
Childbirth (HATCh): intervention scripts 1 and 4. Aus J Clin Exp
Hypn 2007;35:83–94.
30 Cyna AM, Andrew MI, Whittle C. Hypnosis Antenatal Training for
Childbirth (HATCH): intervention scripts 2 and 3. Aus J Clin Exp
Hypn 2008;35:250–63.
31 Gafner G, Benson S. Eye fixation. In: Handbook of Hypnotic
Inductions. New York, NY: WW Norton; 2000. pp. 14–20.
32 Spiegel H. An eye-roll test for hypnotizability. Am J Clin Hypn
1972;15:25–8.
33 Cox JL. Detection of postnatal depression scale. Brit J Psych
1987;150:782–6.
34 Spielberger CD. Stait Trait Anxiety Inventory. Menlo Park, CA: Mind
Garden, 855 Oak Grove Ave., Suite 215, 94025, 1970 [http://
www.mindgarden.com/products/staisad.htm]. Accessed 24 May
2013.
35 Barber T, Wilson S. The Barber suggestibility scale and the creative
imagination scale: experimental and clinical applications. Am J Clin
Hypn 1978;21:84–107.
36 Spielberger CD, Gorsuch RL, Lushene RE, Vagg PR, Jacobs GA.
Manual for the State-Trait Anxiety Inventory. Palo Alto, CA:
Consulting Psychologists Press, 1983.
37 Millar K, Jelicic M, Bonke B, Asbury AJ. Assessment of preoperative
anxiety: comparison of measures in patients awaiting surgery for
breast cancer. Brit J Anaesth 1995;74:180–3.
38 Teiss
edre F, Chabrol H. Detecting women at risk for postnatal
depression using the edinburgh postnatal depression scale at 2 to 3
days postpartum. Can J Psychiatry 2004;49:51–4.
39 Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of
depressed mood during pregnancy and after childbirth. BMJ
2001;323:257–60.
40 Cyna AM. Induction of labour using switchbox imagery during
hypnosis. Aus J Clin Exp Hypn 2003;31:74–87.
41 Fergusson D, Aaron SD, Guyatt G, H ebert P. Postrandomisation
exclusions: the intention to treat principle and excluding patients
from analysis. BMJ 2002;325:652–4.
42 Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous
support for women during childbirth (Cochrane Review). Cochrane
Database Syst Rev 2012: Issue 10. Art. No.: CD003766. doi: 10.
1002/14651858.CD003766.pub4.
43 Madden K, Middleton P, Cyna AM, Matthewson M, Jones L.
Hypnosis for pain management during labour and childbirth.
Cochrane Database Syst Rev 2012; Issue 11. Art. No.: CD009356.
doi: 10.1002/14651858. CD009356. pub2.
44 Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M,
et al. Pain management for women in labour: an overview of
systematic reviews. Cochrane Database Syst Rev 2012; Issue 3. Art.
No.: CD009234. doi: 10.1002/14651858.CD009234.pub2.

Commentary on ‘Hypnosis antenatal training for childbirth

(HATCh): a randomised controlled trial’
This trial provides a good example of a multi-arm study. Multi-arm studies are becoming more prevalent in medical
research. The main advantage to this type of study is that they allow the testing of more than one potential or promising
intervention. In the example cited above there are two intervention arms: a group with hypnosis plus CD and a group
with CD only, and the study is then completed with a third control arm that received no intervention above treatment
as usual. Comparing the two intervention arms with a shared control arm reduces the required sample size by 25%, and
in turn can reduce both the time and cost required to conduct the study (Freidlin et al., Clin Cancer Res 2008;14:4368–
71). It has also been suggested that multi-arm studies may be more attractive to potential participants because it
increases the chance that they will be randomised to a treatment arm rather than the control arm.
In general terms, multi-arm studies are designed and analysed in a similar way to the traditional two-arm study
(Appraising multi-arm RCTs, www.clinicalevidence.bmj.com). Prior to starting the study the comparisons to be made
should be listed and a formal sample size estimated. An interim analysis may prove valuable, after 50% of the partici-
pants have completed the study. This will allow any arms that are unlikely to show efficacy to be identified and dropped
from the study (Watson and Jaki Stats Med 2012;31:4269–79). This, in turn, will reduce the required sample size, and

ª 2013 RCOG 1257

 Cyna et al.

possibly shorten the recruitment time and cost. This type of adaptive design is becoming the norm in most clinical tri-
als.
A more controversial issue in the design and analysis of multi-arm studies is the use of multiple testing (Freidlin
et al., Clin Cancer Res 2008;14:4368–71; Appraising multi-arm RCTs, www.clinicalevidence.bmj.com). Most studies are
powered to detect a difference in the primary outcome at the 5% significance level. Statistically this means that there is
a 5% chance of rejecting the null hypothesis when it is actually true; however, when there is more than one primary out-
come being tested the risk of rejecting the null hypothesis increases as the number of tests increase. Consequently, when
two intervention arms are being compared with a common control arm there could be an 8% risk of obtaining a false
result. There are a number of adjustments that can be made to reduce this risk, one of the simplest and commonly used
approaches is known as the Bonferroni correction, which divides the initial significance level by the number of tests
being performed, so if two tests were being carried out, with an initial significance level of 5%, then the significance level
of each individual test would be 2.5%. However, it is now being argued that if the two comparisons were made in sepa-
rate studies then no correction would be required. Consequently, a more realistic approach may be to use the initial sig-
nificance level, e.g. 5%, if the tests are independent, and to apply a Bonferroni correction or other adjustment method if
the tests are related.
In summary, multi-arm studies can reduce the required sample size when comparing two or more interventions, com-
pared with the more traditional approach of undertaking a separate study for each intervention under consideration.
Reducing the sample size and ultimately the cost of studies increases the probability of obtaining definitive results. &

S Lane
Department of Biostatistics, University of Liverpool, L69 3GS, UK

Journal club

Scenario
During her routine antenatal visit, a patient in her third trimester of pregnancy was keen to discuss analgesia and relaxa-
tion techniques during pregnancy. She asked ‘One of my friends had hypnosis when she was pregnant. Does it work?’

Structured question

Participants Women between 34+0 and 39+0 weeks gestation, planning a vaginal birth
Intervention (i) Group hypnosis sessions plus hypnotherapist-guided audio CDs
(ii) 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.
Study design Randomised controlled trial (1:1:1 design)

Discussion points
1. Background: What is hypnosis? What are the potential risks and benefits of using hypnosis before and during child-
birth?
2. Methods: Critically appraise, do not simply accept on face value, the methods of this trial. In particular, what are the
potential concerns of analysing participant data by a researcher unblinded to allocation?
3. Results: What are the ethical and practical concerns of protocol violations? Are there recognised methods to deal with
these concerns?

1258 ª 2013 RCOG

 The Hypnosis Antenatal Training for Childbirth trial

4. Relevance to your practice: Were the demographics of the participants in this trial similar to your practice? How does
it affect your interpretation of this study?
5. Take-home message: In a single sentence, how would you describe the available evidence of antenatal hypnosis for
pain relief in childbirth? (Data S1)

EYL Leunga & D Siassakosb

a
Women’s Health Research Unit, Centre of Public Health and Primary Care, Queen Mary,
University of London, Yvonne Carter Building, 58 Turner Street, E1 2AB, London, UK
b
School of Clinical Sciences, University of Bristol, The Chilterns, Southmead Hospital, BS10 5NB, Bristol, UK

Join us at #BlueJC: You can collaborate with us to host a #BlueJC session. Find out more on our Journal Club page at
www.BJOG.org. Follow @BJOGTweets to stay updated on scheduled #BlueJC sessions. For background of #BlueJC,
please refer to BJOG 2013;120:657–660. http://bit.ly/10VaiRZ

ª 2013 RCOG 1259