VOL. 4 NO.

1 JUNE 2020

IJNP (Indonesian Journal of Nursing Practices)

Vol 4 No June 1, 2020 : 37-45

Siti Khuzaiyah1, Anies Anies2, Sri The Effects of Hypnosis Relaxation

Wahyuni3 Towards Fetus Heart Frequency and
1
Universitas Muhammadiyah Pekajangan
Pekalongan Vital Signs among Pregnant Women
2
Universitas Diponegoro
3
Poltekkes Kemenkes Semarang with Pre-eclampsia
Corresponding Author: Siti Khuzaiyah
Email: khuzaiyahpenulis@gmail.com

Article Info Abstract

Online : http://journal.umy.ac.id/index.php/ijnp
Background: One of the causes of Maternal Mortality Ratio (MMR)
ISSN : 2548 4249 (Print)
: 2548 592X (Online) in Indonesia is pre-eclampsia. Mothers with pre-eclampsia disorder
DOI : 10.18196/ijnp.41106 who are followed by anxiety tend to have specific vital sign change
included increasing blood pressure, heart rate, respiratory rate, and
fetus heart rate. Pregnant suffered pre-eclampsia should keep the
balance of mind and emotion, as well as to reduce a complication of
pre-eclampsia towards mothers and their fetus.
Objective: The objective of this study was to analyze the effects of the
relaxation hypnosis on fetus heart rate and vital signs of pregnant
women with pre-eclampsia.
Method: This study was a quasi-experiment with a pretest-posttest
design. The total subjects were 32 pregnant women with pre-
eclampsia, which selected by purposive sampling techniques. The
researcher did hypnosis relaxation for three times. a Wilcoxon test
was used to analyze the paired bivariate for systolic blood pressure,
while the Mann-Whitney test and independent t-test were used to
analyze fetus heart frequency.
Result: This study shows that hypnosis relaxation can reduce the
systole blood pressure (p-value = 0.000; CI=12.185-23.109), reduce
diastole (p-value = 0.000; CI= 8.630 – 14.311), reduce heart rate (p
value = 0,004; CI= 2.07 – 8.989) and reduce respiratory rate (p value
= 0.000; CI = 2.785 – 6.275). In terms of the effect on the fetus,
hypnosis relaxation affect the fetus heart rate (p value = 0,000; CI =
5.834 – 13.930).
Conclusion: Hypnosis relaxation influences the change of fetal heart
rate and vital signs of pregnant women with pre-eclampsia.

Keywords: Fetal heart rate; Hypnosis relaxation; Pre-eclampsia; Vital

signs

INTRODUCTION pre-eclampsia as the significant causes (28%)

Based on the Health Demography Survey of (Health Department of Central Java Province, 2020).
Indonesia in 2015, Maternal Mortality Ratio (MMR)
in Indonesia reached 305/100.000 birth of life. Pre-eclampsia is a specific syndrome suffering
Meanwhile, the target of MMR from Sustainable pregnant in more than 20 weeks of age gestation-
Development Goals (SDGs) was 70/100.000 birth of who was healthy tension in previous age. The signs
life (Health Department of Pekalongan District, of pre-eclampsia are increasing blood pressure
2019). In Central Java, in 2019, the MMR reached (140/90 mmHg) and following by appearing of
76,93/100.000 delivery of life with hypertension and protein urine (Cunningham et al. 2010). Pre-
eclampsia could affect on fetal well-being. Babies

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who are born by mother with pre-eclampsia, tend to Several measurements have been taken to control
have a few problematic temperament styles in the pre-eclampsia. In the case of a mother with a high
first three months after birth. Moreover, its risk of pregnancy, including pre-eclampsia, the ways
negative impact was amplified by the mother's were a consultation to the obstetricians and hospital
antenatal depression (Nomura et al., 2014). visits to monitor blood pressure once a week
routinely. However, no psychological and spiritual
Mothers with pre-eclampsia disorder who are treatment has been taken. Hypnosis is the kind of
followed by anxiety and stress tend to have specific appropriate complementary therapy with minimum
vital sign change included increasing blood pressure, side effects. Hypnosis is safe, efficient, and
heart rate, respiratory rate, and fetus heart rate. economical compared to other complementary
The physiologic response of fear is activating the therapies because no specific equipment is needed
center nervous system to enable the hypothalamus- (Saha et. al., 2012; Shorofi, & Arbon, 2017). The
pituitary-adrenal axis and sympathetic nervous other additional therapy methods need more
system signed by increasing the frequency of heart material, such as acupuncture, aromatherapy, and
rate and blood pressure (Agorastos et al. 2019). music therapy. Such as lavender aromatherapy in
However, Kafali, Derbent, Keskin, Simavli, & lowering blood pressure, health care should prepare
Gözdemir (2011) are evaluating the association some drops of aromatherapy and diffuser (Maisi,
between maternal anxiety and baseline FHR claimed Suryono, Widyawati, Suwondo, & Kusworowulan,
that stress-induced high maternal state anxiety 2017); or they need a banana when using ambon
increased baseline FHR. banana as the alternative way in reducing blood
pressure (Susanti, & Resti, 2019)
There is a strong relationship between mother
psychology and of the fetus. Studies have shown Moreover, any drugs, surgery, and special medic
that maternal exposure to stressful events during equipment are not required to give hypnosis; only
pregnancy is linked to adverse outcomes in children use the power of suggestion, which will relax the
(Ferrari, Faccio, Peccatori, & Pravettoni, 2018). patients directly and make them comfortable
Antenatal anxiety predicts poor infant physiological, quickly (Iserson, 2014; Larasati & Wibowo, 2012).
mental, and psychomotor development as well as Yoganita, Sarifah, & Widyastuti (2019) suggested
behavioral and emotional difficulties in early that nape massage and hypnosis can reduce blood
childhood (O’Donnell et al., 2017; Vehmeijer, pressure, either systolic (15.62 mmHg) or diastolic
Guxens, Duijts, & El Marroun, 2019). Thus, the (6.72 mmHg). Hypnotherapy can also overcome
mother should keep the balance if the emotion to stress, relax the body, inhibit cortisol hormone
gain happiness and peace along with the pregnancy. secretion, and this condition prevents
The healthcare provider can choose Hypnosis vasoconstriction of blood vessels so that blood
relaxation as an alternative way to keep the balance pressure decreases (Purnomo, Nur, Rahim, &
of the body (Andriana, 2011). A combination of Pulungan, 2020)
standard care and a brief hypnosis intervention
holds sufficient promise for antenatal stress relief to In terms of fetal heart rate (FHR), relaxation reduced
justify testing its efficacy in larger groups of the basal fetal heart rate (Akbarzade, Rafiee, Asadi,
pregnant women (Legrand et al., 2017). & Zare, 2015). In regards to this study, hypnosis,
which has a function as relaxation, was used to
In 2014, from 35 District in Central Java, Pekalongan stabilize both fetus heart rate and mother vital
district was the 7th district with the highest MMR up signs. The study aimed to analyze the impacts of the
to 29 cases (Health Department of Pekalongan relaxation hypnosis on fetus heart rate and vital
District, 2014). The data of The Health Department signs of pregnant women with pre-eclampsia.
of Pekalongan district indicated that the MMR in
2018 was 69/100.000 life birth (11 cases), which METHOD
pre-eclampsia was one of the causes of MMR This study was a quasi-experimental with a pretest-
(Health Department of Pekalongan District, 2019). posttest with a control group design. The variables
were hypnosis relaxation, fetus heart rate, and

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mother's vital signs. The population in this study services included vital sign check-up routinely,
were pregnant women with pre-eclampsia in the health education, and emotional support.
working area of the Health Department of
Pekalongan District in 2016. The criteria were under The main instruments in this study were
the supervision of the Health Department of sphygmomanometer, stethoscope, watch, doppler
Pekalongan District, including in the top eight (digital fetus heart rate meter), and questionnaire,
Community Health Center that had similar regional which could record: age, gravida, BMI, gestational
characteristics and had the highest incidence of pre- age, and the data of vital signs and fetus heart rate.
eclampsia in 2016. The Community Health Center
with the highest prevalence of pre-eclampsia in Data collected after obtaining a research permit
2016 is Kedungwuni II, Kedungwuni I, Karangdadap, from all relevant parties, and the researcher
Bojong I, Wiradesa, Tirto, Wonopringgo, and coordinated with the Community Health Centers in
Buaran. the Pekalongan District Health Department's
working area. Data collection assisted by the
The number of samples needed for each group was midwives and the staff of the Community Health
16 respondents (Federer, 2012). To maintain the Center selected.
number of member groups in enough quantities, the
researcher made a correction number by Univariate analysis was used to describe the data in
determining a dropout value of 10% (f: 0.1). Based percentage form. The researcher used a test of
on the sample calculation and drop out correction homogeneity to test whether variants were
considerations, the number of respondents needed homogenous or not. Based on the homogeneity test
was 18 respondents in each group. Sample collected of age and gravida variable, age and gravida showed
by purposive sampling technique. that they were homogeneous with a p-value of age
0.252 and the p-value of gravida 0.155.
Patients who were determined to be respondents
must have met the inclusion criteria and eliminate A Shapiro Wilks test was used to test the normality
the patients who met the exclusion criteria. The of the data. The test results showed the Asymptotic
inclusion criteria in this study were: did not suffer Significance >0.05 (was normally distributed) or
from an infection, that was defined by fever in the Asymptotic Significance <0.05 (the data distribution
last three days, or signs of inflammation in the body was not normal). In the control group, the results of
(Color, Dolor, Rubor, Tumor, Functionolaesa), the the normality of systolic blood pressure test before
fetus lives, a single embryo, did not suffer from treatment were 0.001, diastole before intervention
chronic diabetes mellitus, mothers were willing to 0.002, diastole after those was 0.002, gravida 0.026,
be a respondent and were ready to be given and length of education was 0.001. This study
standard pregnancy care and hypnosis (for the showed that systolic blood pressure before
intervention group), and they were willing to do treatment, systole after those, diastole before
standard pregnancy care (for the control group). those, gravida, and education level have abnormal
data distribution. Meanwhile, normality test results
A random technique used to determine the group for systole after intervention were 0.053, age 0.591,
members. Both groups then performed initial tests BMI 0.36, and gestational age 0.089. This study also
for vital signs and the fetus's heart rate. The showed that systolic blood pressure after hypnosis,
intervention group then gets the intervention, i.e., age of respondent, BMI, and gestational age have
hypnosis relaxation and regular services included normal data distribution.
vital sign check-up routinely, health education, and
emotional support. The hypnotherapy had been In the treatment group, the normality test results
done by a certified hypnotherapist using a for diastole before treatment were 0.002, gravida
standardized procedure. The intervention was done 0.009, and length of education was 0.001. This
in the patient's home and was carried out three research showed that diastole before hypnosis,
times with the distance of each therapy for one day. gravida, and education level had abnormal data
The researcher re-examined the vital signs and fetus distribution. Meanwhile, the results of the normality
heart rate on day three after treatment. On the data of the systole-in the treatment group was
other hand, the control group received regular 0.096, systole after treatment 0.512, diastole after

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treatment 0.058, age 0.598, BMI 0.144, and respondents in the experimental group and 16
gestational age 0.54. This study showed that systole samples in the control group.
before hypnosis, systole after those, diastole after
those, age, BMI, and gestational age had normal Characteristics of respondents shows in Table 1.
data distribution. Based on age showed that the average age of
respondents in the control group was 32 years, with
Wilcoxon test was used to analyze the paired a minimum age of 20 years and a maximum age of
bivariate for systolic blood pressure before and after 40 years. In the treatment group, the average age of
the control group treatment, diastole before and respondents was 32 years, with a minimum age of
after the control group treatment. Meanwhile, the 21 years and a maximum age of 42 years. Based on
bivariate analysis paired the systole before and after the categorical frequency distribution, there were
the treatment group using paired t-tests because 22 (68.8%) and in the healthy age range (20-35), and
the data had a normal distribution. 10 (31.2%) were in the high-risk age range (<20 or
>35). Based on gravida showed that the average
The researcher used linear regression analysis for respondent of the third gravida with a minimum of
further analysis. In the non-paired data analysis with first gravida and maximum of the sixth gravida. In
the normal distribution, the data analysis was contrast, the treatment group showed the average
carried out using an Independent t-test, while the gravida of the treatment group was the third
Mann-Whitney test analyzed the data with the gravida, with minimum was the first gravida, and the
abnormal distribution. Meanwhile, the data of fetus maximum was the sixth gravida. The data frequency
heart frequency appeared normal and abnormal. was 11 primigravidas (34.4%), 16 multigravidas
Thus the Mann-Whitney U test and independent t- (50%), and five grande-multiparas (16.6%).
test were used to analyze the data. IBM SPSS
Statistic version 23 was used to analyze the data. Characteristics of respondents based on length of
education showed that the average level of school
In this study the implementation of research ethics in the control group was 7.87 ± 2.66, minimum
followed these steps: assigning an informed consent education level at 6 (elementary school), and
form, using an anonymity form, keeping the highest education was 12 (high school). Meanwhile,
confidentiality, caring for self-determination (free to the average duration of treatment group education
participate or not participate), giving benefits, doing was 7.81 ± 3.06, with a period of at least six years
veracity, protecting from discomfort and harm (elementary school), and the most extended
condition, and passing ethical clearance. The ethical education period was 17 years (bachelor). Based on
issue was obtained from the Research Ethics body mass index (BMI) showed that BMI in the
Commission of the Faculty of Public Health, control group was 24.09, with the lowest BMI 20 and
Diponegoro University, Semarang. Besides, the the highest BMI 29. In the treatment group, the BMI
therapeutic process was carried out by researchers, average was 23.51, with the lowest BMI 19 and the
namely midwives, who have been certified most elevated BMI 29. Based on gestational age
Hypnotherapist (CHt). showed that in the control group, the average
gestational age was 32.2 weeks with the youngest
RESULTS gestational age of 20 weeks, and the oldest
We found 18 respondents in the experimental group gestational age was 41 weeks. Whereas in the
and 18 respondents in the control group. At the time treatment group, the average gestational age was
of the research, process dropout occurred in the 33.8 weeks with the youngest gestational age of 20
experimental group of two respondents because weeks, and the oldest gestational age was 41 weeks.
respondents refused to do the second intervention Characteristics of respondents by occupation
and experienced labor before completing the showed that 16 (60%) respondents worked as textile
therapy, and drop out in the control group of 2 workers and 12 (37.5mmHg) mothers who did not
respondents because the health care referred work.
patients. The final number of samples was 16

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Table 1. The comparisons of blood pressure pre-post intervention (n= 32)

Variable Pre Post Blood pressure change P-
Blood pressure Mean±SD Min-Max Mean±SD Min-Max Decreased Increased No change Value
Control group
Systole 155.31±27.415 130 – 240 150.06±36.852 86 - 245 9 (56.3%) 2 (12.5%) 5 (31.3) 0.059a
Diastole 95.5±15.535 80 – 140 95.5 ± 15.535 80 - 140 6 (37.5%) 0 (0%) 10 (62.5%) 0.02b
Experiment group
Systole 146.88±13.889 130 – 170 126.88 ± 13.765 106 - 160 15 (93.8%) 0 (0%) 1 (6.3%) 0.025c
Diastole 9.50 ± 7.746 80 – 100 81.88 ± 12.230 60 - 100 13 (81.3%) 1 (6,3%) 2 (12.5%) 0.002d

Table 2. The comparison of the frequency of the pulse, respiratory, and fetus heart between the pre-post
intervention (n = 32).
Univariate test n (%) Paired sample
pre-post
Variable Mean ± SD Min-Max P-
intervention test
Value
Decreased Increased No change value
Pulse rate among mothers in the control group
Pre 91.25 ±10.927 74-110
9 (56.25%) 6 (37.5%) 1 (6.25%) 1.485 0.158g
Post 88.50 ±8.929 76-100
Pulse rate among mothers in the experiment group
Pre 92.25 ± 10.376 72-116
14 (87.5%) 1 (6.3%) 1 (6.3%) 3.159 0.002h
Post 84.69 ± 10.268 6610-14670
The respiratory rate among mothers in the control group
Pre 24.06 ±3.151 18-30
11 (68.8%) 5 (31.3%) 0% 0.871 0.397g
Post 23.38 ±3.557 16-30
The respiratory rate among mothers in the experiment group
Pre 24.50 ±3.615 18-30 0.000
15 (93.8%) 1 (6.3) 0% 5.537 g
Post 18.69 ±3.198 16-25
Fetus heart rate among mothers in the control group
Pre 141.94±9.344 128-155 0.692
9 (56.3%) 6 (37.5%) 1 (6.3%) 0.405 g
Post 141.38 ±8.229 130-152
Fetus heart rate among mothers in the experiment group
pre 143.81 ±12.411 115-160 0.000
14 (87.5%) 1 (6.25%) 1 (6.25%) 5.870 g
post 132.50 ±8.602 110-145

Table 3. The comparison of the delta value of the frequency of the pulse, respiratory, and fetus heart between
control – experiment group (n = 32).
Value CI
Variable
Score P-Value
Differences between pulse rate in control and experiment group 3.159 0.016i undefined
Differences between respiratory rate in control and experiment group -3.903 0.000j (-7.807) - (-2.443)
Differences between fetus heart rate in control and experiment group -4.524 0.000j (-15.603)- (-5.897)

Table 1 shows that in the experiment group, there significant differences between pre-intervention
were significant differences between systole and and post-intervention in the experiment group
diastole pre and post-intervention with p-value either for a pulse, respiratory, and fetus heart rate;
0.025 and 0.002. Meanwhile, in the control group, these were 0.002, 0.000, and 0.000,
the only diastole that was considerable indifference respectively. Table 3 suggests that there were
with the p-value was 0.02, and there was no significant differences between the delta value of
significant difference in systole (p-value 0.059). the pulse rate between the control and experiment
group (0.016), respiratory rate (0.000), and fetus
Table 2 indicates that there were no significant heart rate (0.000).
differences between pre-intervention and post-
intervention in the control group either for pulse DISCUSSION
rate (p-value= 0.158), respiratory rate (0.397) or Hypnosis gives positive effects on blood pressure
fetus heart rate (0.692). Meanwhile, there were decrease within pregnant mothers with pre-

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eclampsia. Findings showed that there was a Furthermore, the stress perceived by the patients in
significant effect of hypnosis towards those. the experimental group is lower than the scores
Hypnosis is an effective communication method reported at the beginning (U = 109.5, N = 52; p =
which passes directly to the critical factor. Hypnosis 0.003). Another study find that hypnosis reducing
reduces blood pressure through steps (1) relaxation; hypertension both in a short time, middle, and long-
(2) parasympathetic nerve activation; (4) reducing term (Kekecs, Szekely, & Varga, 2016). A significant
cardiovascular activity; (5) increasing vasodilatation; lowering of both systolic and diastolic pressures was
(6) increasing VEGF; (7) reducing SFlt-1 in the plasma obtained in both the no drug and drug groups
and; (8) reducing blood pressure (Olendzki, Elkins, receiving hypnosis treatment (Deabler et al., 2011).
Slonena, Hung, & Rhodes, 2020).
People in hypnosis relaxation state will have an
On the hypnosis treatment, pregnant women- entirely relaxed body, calmed, similar to sleep
subjects- were lied on the left side of the stomach; condition, but they do not have a total loss of
two small pillows were put under the abdomen and conscious (Beevi, Low, & Hassan, 2016). Moreover,
between two legs. Rested on the left side of the Vanhaudenhuyse, Laureys, & Faymonville, (2014)
abdomen gives benefits both for mother and baby. argued that in hypnotherapy states, there is a
On the one hand, the baby will get the maximal flow stimulus to the reticular activator system in the
of blood and nutrition to the placenta since the vena brain. It causes nervous autonomy response,
cava inferior located at the back right side of spin including pulse decrease, blood pressure decrease,
flow back the blood flow from the lower part of the and respiratory rate decrease. Besides, it will also
heart. On the other hand, the mother with high control the feeling, emotion, and stress. Relaxation
blood pressure will get the maximum effect of blood will inhibit the increase of the sympathetic nerve
pressure decrease, and this is suitable with a activity; therefore, it can reduce the number of the
statement that people in lay positions are having hormone caused dysregulation of the body. The
lower blood pressure (Grindheim, Estensen, parasympathetic nervous system has a
Langesaeter, Rosseland, & Toska, 2012). When the contradiction function with the sympathetic nerve
women turned from the left lateral to supine to the system, and it slows the work of internal body
right lateral positions, the blood pressure invariably systems. The effects of the relaxation are reducing
rose slightly as the women were (Cicolini et. all., pulse, respiratory rhythm, blood pressure, muscle
2011). tension, metabolic level, and the production of the
stress hormone. As a result, the whole of the body
Therefore, this study suggested that hypnosis starts to get maximum function and healthier
effecting on blood pressure decrease both in systole circumstances with the higher of the healing energy,
and diastole among pregnant women with pre- restoration, and rejuvenation (Pal, Pal, & Wal,
eclampsia, furthermore, it will drop mortality risk on 2019). Hypnosis relaxation stabilizes fetus heart rate
mother affected by pre-eclampsia. The mean of the in pregnant women with pre-eclampsia. Fetal heart
systole and diastole decrease was 20 mmHg and 7.5 rate (FHR) monitoring is an essential tool for fetal
mmHg, respectively. Clinical hypnosis-called welfare assessment (Reddy, & Jim, 2019). Relaxation
hypnotherapy also makes a mother more relax, during pregnancy is associated with salutogenic
stabilizes the pulse frequency, respiratory rate, and effects that include regulation of emotional states,
fetus heart rate frequency. Hypnosis relaxation physiology, and positive impact both on fetal
creates a depth rest, either physical rest or spiritual behavior and on obstetric and neonatal outcomes
and emotional rest. Relaxation is a technique used (Fink, Urech, Cavelti, & Alder, 2012).
to support and obtain depth relaxation to low the
unwanted signs and the symptoms in the body (e.g., Fetus heart rate illustration shows how the
pain, muscle stress, and anxiety). This result condition of the fetus's health. Based fetus heart
supports the research conducted by Holdevici rate decreases sharply along with the increasing
(2019) that Ericksonian hypnosis can reduce gestation age as the result of the maturity of
essential and secondary hypertension with p-value parasympathetic tonus. The researcher measured
< 0.005 (U = 23.7; N = 52). the fetus's heart rate (FHR) in one full minute

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(Baston & Jennifer, 2012). However, in the reality of the limitations of this study. This study took about
service, that FHR measurements on prenatal care six months, just for taking the data. It occurred
are only to find out whether there is a sound, because of the difficulties in finding respondents
without knowing the frequency, so that it cannot who met inclusion criteria.
detect if there is a possibility of irregularities or rates
lower than 110x/minute and higher than CONCLUSION
160x/minute (Chabibah & Laela, 2017). Bradycardia Hypnosis relaxation influences the change of fetus
is a condition when the FHR is less than 110 heart rate and vital signs of pregnant women with
x/minute) is defined as bradycardia. In contrast, pre-eclampsia, including blood pressure, heart rate,
tachycardia is a condition when the FHR is higher and respiratory rate. Hypnosis relaxation also
than 160 x/minute, which is caused by factors such influences the stabilization of the fetus's heart rate
as fetus hypoxia, anemia, and drugs (Holmes & in pregnant women with pre-eclampsia. Health care
Baker, 2011). services should include hypnosis relaxation as an
alternative way for caring for pregnant women with
There are various factors influencing fetus heart pre-eclampsia so that the fetus and mother's
rate, including the mother's position, uterine welfare can be improved.
activity, and the age of the mother's pregnancy due
to the balance of maturity of the sympathetic and ACKNOWLEDGEMENTS
parasympathetic nerves, fetus stress, and anxiety Thank you conveyed to The Department of
felt by pregnant women (Gondo & Suwardewa, Research, Community Service, and Publication of
2011). Relaxation hypnosis conditions will make The University of Muhammadiyah Pekajangan
pregnant women relaxed and calm. Someone who Pekalongan Indonesia for supporting this study.
has a quiet mind, his heart rate will be regular and Besides, thank you also delivered to The Universitas
not too fast. In contrast, a stressed mother, his heart Diponegoro for the ethical clearance certificate.
rate will tend to be faster. Mother and baby have
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