Patient-Centered Imagery in Obstetrics

By Stein, Harise

ABSTRACT Patient centered imagery, often termed interactive or integrative imagery, focuses on helping the patient envision her own images for health and well-being. Because these images come directly from the patient, they can be more meaningful and powerful, and provide valuable insight into unspoken fears as well as intuition about what is needed.

Over three thousand years ago, a woman with infertility or a problem pregnancy would place a clay sculpture of a uterus on the altar at the Temple of Asclepius, the Greek God of medicine. This was her way of using imagery for healing.

Today we can utilize imagery tools such as art therapy or guided imagery, a very effective imagery format used with individuals, groups, or CDs, and which is usually uni-directional – meaning that images come from the practitioner to the patient. Another method is a more customized one-on-one approach termed interactive imagery^sup SM^ or integrative imagery. In this type of imagery, both the patient and guide interact with each other, and the patient interacts with the images she creates. As a more patient-centered type of imagery, the purpose of the practitioner “guide” is not to provide the images, but to help the patient find her own.

Because these images come directly from the patient herself, they can be more meaningful and can provide insight about barriers, unspoken fears, and intuition about what is needed. In addition, because these images are often so deeply entwined with emotion, consciously changing the images themselves can have a powerful effect on well-being.

What follows are some clinical cases I have encountered in my private practice. The details have been changed only enough to protect the identities of the individuals being discussed.

CASES

#1 – 38-year-old, first pregnancy, 7 weeks pregnant

This patient was sent over from an in vitro fertilization clinic, having developed extreme anxiety after her 7-week ultrasound showed a normal pregnancy with heartbeat. (For a variety of reasons she felt that this was her “last chance.”) She was trembling, hyperventilating, and unable to focus on relaxation breathing. She stated that her mind kept saying over and over “I’m going to lose the baby. I’m going to lose the baby.”

Realizing she was too agitated to proceed in the usual fashion, I simply asked, “If you could draw a picture of how you feel right now, what would it look like?”

Immediately she responded, “Like a top spinning out of control.”

I pointed to the carpet. “Why don’t you go ahead and imagine that top spinning on the carpet here. What could you do to stop it from spinning?”

“I could pick it up and hold it, and put it in my pocket.”

“Why don’t you go ahead and do that?”

She stared at the carpet, made a few small motions with her hands, put her hand in her pocket, and then took a deep breath, relaxed her shoulders, and looked up steadily for the first time. We were then able to discuss relaxation methods, plus a referral to a psychologist for support during her pregnancy.

Wl – 32-year-old, third pregnancy with one living child, 21 weeks pregnant, prior history of preterm labor

This patient was an energetic, very athletic woman, who ran her own business out of her home, necessitating frequent sales trips out of state. She had been quite dismayed that her previous pregnancy had required bedrest at 29 weeks, and hospitalization and medication for premature labor, ending in a 37-week delivery. Now at 21 weeks with her next pregnancy, her obstetrician had told her to anticipate more of the same, in addition to which she now had a toddler to care for. She was angry and frustrated at the thought of having to stay in bed, of the disruption to her business, and wanted to know why her uterus couldn’t be “normal.”

After being taught relaxation skills, she was asked to create an image of her uterus, with which she then was guided to have an interaction. She relayed that her uterus was a red balloon floating in the air. There were a few bumps on it, and it was open on the bottom. She told her uterus how angry she was. The uterus replied that it wanted to be a safe place for her baby to grow, and it was doing the best that it could. She was then guided to ask her uterus what it needed from her. It said it needed for her to be healthy, calm, and relaxed, and made several suggestions – that a neighbor’s teen could help out with the toddler, that a cousin could help with the business, that a friend could do massages, etc. When asked to again examine the original image of her uterus, the patient noticed that the bumps had disappeared, and the bottom was now closed.

This patient was seen once at 21 weeks. She reported back after delivery, having gotten to 39 weeks without medication or hospitalization, and only modified bedrest. She had talked to her uterus often, feeling like they “were a team.” When she would experience increased uterine activity, she would lie down thinking, “my uterus needs me to help it,” rather than becoming tense and angry. She actually had an enjoyable pregnancy despite moderate limitations.

#3 – 28-year-old, second pregnancy, no living children, now 36 weeks pregnant, for repeat cesarean

This patient’s first pregnancy had ended in term perinatal death after a traumatic emergency cesarean delivery. She developed depression and post-traumatic stress disorder postpartum. In helping her to prepare for her next delivery, she was taught a variety of breathing, relaxation, and cognitive-behavioral tools. Then we proceeded with a “dress rehearsal” of the upcoming repeat cesarean.

First it was difficult, in her mind’s eye, to just be able to enter the delivery room. Then we were able to talk through in detail all of the steps of what would happen, asking at intervals how she was feeling. She was able to cope fairly well until it was time to make the uterine incision, at which point she became very agitated and upset, saying that there must be something wrong with the uterus, since it hadn’t allowed her first baby to be born. We talked about how the delivery mechanics of last time and this time were different, and of the strong but elastic qualities of uterine muscle. She was asked to palpate the baby’s head just under the cesarean scar where the baby was “just waiting to come out.” She was then guided to ask her uterus about the upcoming surgery. The uterus said it was afraid of being in pain. The patient was reminded that this situation was different – this would be an elective surgery, and there would be enough time for the epidural to take effect. She told the uterus that fact, and asked if it would allow the baby to be born. It said it would. She was then able to continue her rehearsal, and to describe the uterus easily being opened and the baby flowing out with the amniotic fluid. Her subsequent repeat cesarean was unremarkable, and she felt that she was able to cope with the whole situation surprisingly well.

#4 – 29-year-old, first pregnancy, 3 weeks postpartum

This patient had delivered her first child at 30 weeks, and since the delivery three weeks earlier she had been using a breast pump to maintain milk flow. She had a strong sense that she needed to be in the NICU to protect her baby, even though she did not express any quality of care concerns. She neglected her own sleep and nutrition to stay by the baby, and her breastmilk production was decreased to the point that she was going to discontinue pumping.

She was asked to imagine a place where she and the baby could be safe. She chose sitting in a rocking chair in her living room, looking through a large picture window onto the sun shining on her garden. She was asked to imagine in detail holding the baby skin-to- skin, feeling the baby’s mouth, experiencing letdown, imagining the flow of milk – all the while stroking the baby, and noticing her daughter’s expression and personality.

Then the patient was asked to imagine a way wherein she could feel that she was watching over the baby, even when she wasn’t there. She imagined a pink shining light going from her heart to the baby’s heart, that then enveloped her daughter’s whole body. She felt this light could connect them even though they were miles apart. After this experience, she was able to relax more when she was at home, imagining whenever she wanted that she was sending her love and protection to the baby, especially while pumping. Her milk volume significantly improved.

DISCUSSION

These examples identify several applications of imagery in general, used here in a patient-centered fashion.

Symptom Control

Case #1 demonstrates the use of imagery for symptom control, in this instance anxiety. Symptom control is a very common use of imagery, and there is an extensive body of medical literature showing benefits in a wide variety of areas including pain management, gastrointestinal function, cancer treatment, surgery, sports medicine, and even stroke rehabilitation.

When guiding a patient interactively to come up with her own images in order to modify symptoms, the guide can then point out that the patient accomplished this by herself. Doing so is very self- empowering for patients, whose situations may have led them to feel helpless and hopeless.

Talking to the Symptom or Body Part

This approach may seem very strange at first reading, but can be extremely effective and in some cases has even been described by my patients as “life-changing.” Encouraging imagery that comes from the patient gets to deep feelings very quickly. In case #2, the patient was able to have a dialog with her uterus, express her anger, and hear its side of the story – that it was “doing the best that it could.” In hearing this, she was able to develop compassion for her uterus and a desire to want to help it do its work. In reality she was expressing compassion for herself. Her uterus also gave her suggestions for self-care, which was basically the voice of her own intuition talking to her about what was needed. Imagery Rehearsal

Imagery rehearsal is an extremely useful technique for any kind of medical procedure or even patient self-care issue. When the patient leads the rehearsal herself, you can find out what she does and doesn’t know, her misconceptions, and (as in case #3) her fears. This patient had verbally and intellectually blamed her previous experience on the obstetricians who had taken care of her, but secretly believed that her uterus had caused the problem. In being able to identify and express her fear, and then re-evaluate that fear from both an intellectual standpoint (pointing out that the baby’s head was right there rather than stuck deep in the pelvis) as well as an emotional one (telling the uterus it would be protected from pain, asking it to allow the baby to be born, and being able to visualize that happening) she was able to improve her confidence and ability to cope in a difficult situation.

Personal Place

Many women who have had traumatic obstetrical or gynecological (ob-gyn) experiences are unable to feel safe. Some of them may meet criteria for post-traumatic stress disorder (PTSD), and I believe that there is much more formal and subclinical PTSD from ob-gyn experiences than is recognized. Being able to help a patient find a place where she can feel safe may be one of the most effective tools that imagery has to offer. In case #4 the patient was able to find that safety not only for herself, but her child, and in doing so increase her feeling of control in the frightening and unstable world of the NICU. In addition, this case demonstrates the use of imagery to improve milk production (Feher et al. 1989).

Caveats

This last case brings up an important issue in any use of imagery, but especially so when done interactively and coming from the patient. Some healthcare practitioners believe that patients shouldn’t use imagery, because it puts too much personal responsibility on the patient. What if in case #4 the patient’s baby had died? Would the patient feel worse because she hadn’t been able to “protect” her daughter in the way she imagined? I would strongly answer that that would not be the fault of the imagery process, but of how it was presented.

When I first see a patient I explain that medical conditions have many factors, including genetics, environmental exposure, etc., and that she as the patient is not responsible for “curing” herself. I explain that doing imagery, just like eating well and getting enough rest, is one more positive thing she can do to improve her well- being. I also explain that although imagery will be beneficial and that anything is possible, no one can say to what extent imagery will cause a desired outcome.

A second caveat, directed at readers, is to not do interactive type imagery without proper training. While these methods may seem superficially simple, my very first imagery patient, while enjoying herself at the beach, began to drown during the session. It was only because I was well-trained that I was able to salvage that situation and turn it into a positive experience for her.

CONCLUSION

Using imagery in a patient-centered fashion can be a very useful tool in obstetrics, being applicable for antepartum symptoms or conditions, delivery, and postpartum issues such as breastfeeding. Because the images come from the patient herself, they can be very powerful – improving not only physiological parameters, but well- being in the form of improved mood, and increased confidence, coping, and self-efficacy.

Two excellent training programs for patient-centered imagery are:

Academy for Guided Imagery

http://www.academyforguidedimagery.com/800/726-2070

Beyond Ordinary Nursing

http://www.integrativeimagery.com/650/570-6157

Feher, S., L. Berger, J. D. Johnson, and J. B. Wilde. 1989. Increasing breast milk production for premature infants with a relaxation/imagery audiotape. Pediatrics 83(1):57-60.

* Harise Stein, MD, is a board-certified obstetrician and gynecologist on the adjunct clinical faculty of the Stanford Ob/Cyn Department, where she is in charge of the Mind-Body Surgery Support Program for gynecology patients. She also has a private practice in Mountain View, CA, where she specializes in mind-body medicine for women’s health. steinmd@earthlink.net

Copyright INTERNATIONAL CHILDBIRTH EDUCATION ASSOCIATION Sep 2007

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