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Parents’ Singing to Fetus and Newborn Enhances Their Well-being, Parent-Infant Attachment, & Soothability: Part Two

February 26th, 2013 by avatar

Regular contributor Penny Simkin discusses the research around parents’ singing to their babies in utero and the post birth benefits.  She also shares how birth professionals can encourage clients, patients and students to start this practice during pregnancy.  Part one of this two part series can be found here. – Sharon Muza, Community Manager, Science & Sensibility


What is the research evidence for postnatal benefits to parents or babies  of singing to the baby before birth?

• Fetuses can sense audio vibrations and rhythms early in pregnancy. Later in pregnancy they hear and distinguish various sounds. (4)
• They recognize their parents’ voices after birth (1)
• Newborns prefer their parents’ voices over the voices of strangers (1)
• Repetitive prenatal reading of one story by one parent every day for weeks results in the newborn’s recognition of and preference for that story. (2)
• Fetuses respond to music by calming, becoming active, changes in FHR (depending on the music) 5,6)
• Premature babies are calmed by calming music. (7)
• Newborns and young babies are calmed by familiar music, as demonstrated by the universal use of lullabies.

Combining these findings, a proposal

In light of all that has been learned about babies, I think we can combine it all into a simple approach to enhance bonding, soothe the baby, empower parents with their own unique tool that no one else, even the experts, can do as well as they. (8) I propose that we who provide care and education for expectant parents urge them to do the following at around 30-32 weeks’ gestation (or earlier or later):

Simple steps to singing to the baby in utero and after birth

1. Choose a song that you like and is easy for you to sing. It might be a lullaby or a children’s song, but it does not have to be. It can be one of your favorite songs or a popular song of the day.

2. Sing it every day. Both parents can sing it together, but each of you should also sing it alone much of the time. It can be played with a musical instrument some of the time, but it also should be played without an instrument much of the time.

3. When your baby is born, after the initial lung-clearing cry, sing the song to your baby. The baby can be in your arms or with a nurse in the warmer. If your baby is crying, try to sing close to his/her ear or loud enough that he/she can hear it at least during the pauses to take a breath.

4. Continue singing it every day, especially during times when your baby is crying (and has been fed; don’t use it as a substitute for feeding!)

5. Sing it when bathing or diapering your baby, when soothing or helping your baby go to sleep.

6. Sing it when your baby is upset and you can’t pick her up, such as when driving in the car and you can’t stop or take the baby out of the car seat; or at a checkup if the doctor is doing something painful.

Maia sings to her sister in utero ©Penny Simkin

If parents feel they can’t sing or are too embarrassed to do it, I suggest choosing a poem that has a nice rhythmic meter, and recite that to the baby. I recommend Mother Goose Rhymes or poems in books by AA Milne, such as “When We Were Very Young” and “Now We Are Six;” or Shel Silverstein’s “Where the Sidewalk Ends” and others.

Film clips showing baby’s reactions to familiar songs 

Recent students in my birth class took my suggestion to heart, singing “Las Mañanitas,” from their Mexican culture, to their unborn baby frequently. The dad would lie with his head on the mother’s pregnant belly as they sang. They even videotaped sessions while the mother was having a non-stress test that showed the baby’s heart rate steadying when the dad was singing, and rising when he was not.  We also see the dad singing to their sweet little daughter right after the birth. Though she cries pretty hard when being suctioned and rubbed with blanket, she calms down with his singing.

I’ve just completed a film for children (9). In the film, we see 4 year old Maia singing  ”Twinkle, Twinkle, Little Star” to her baby sister before birth and again right after birth. Neve, her sister, calms down when she hears Maia singing the familiar song.

Enjoy these heartwarming scenes in the video below.


Maia sings to her newborn sister ©Penny Simkin

In conclusion, when parents sing one (or possibly a few) songs repeatedly to their child, before and after birth, it is a once in a lifetime opportunity to build a unique, meaningful and fun connection with their baby. The child already knows and loves the song as sung by his/her parents more than any other song, sung by anyone else. Parents always have their voice with them and can use it to comfort, soothe, and play with their child for years to come. Parents have the opportunity prenatally to give their baby a gift that becomes a gift for them as well.

Singing to the baby before and after birth is a lovely and very special thing to do. Would you consider introducing this ritual to your students, clients and patients?  Have you already done so?  How has it been received?  Do you have any stories about parents who have practiced this connection? Please share in the comments section, I would love to hear about it.  If we all get the word out to expectant families, it could have a very positive impact.


  1.  Brazelton B. Cramer B. (1991)The Earliest Relationship: Parents, Infants, and The Drama Of Early Attachment . Da Capo Press Cambridge, MA.
  2. De Casper A. 1974, as described in Klaus M, Klaus P, Kennell J. 2000. Your Amazing Newborn. Da Capo Press, Cambridge, MA..
  3. Odent M. 1984, Birth Reborn. Pantheon Books: New York
  4. Klaus M, Klaus P, Kennell J. 2000, Your Amazing Newborn. Da Capo Press, Cambridge, MA.
  5. Verny T, Kelly J. (1982)   The Secret Life of the Unborn Child. Dell: NY
  6. Chamberlain D. (2013) Windows to the Womb. North Atlantic Books: Berkeley, CA.
  7. Lubitzky R, Mimouri F, Dollberg S, Reifen R, Ashbel G, Mandel D. 2010. Effect of music by Mozart on energy expenditure in growing preterm infants. Pediatrics 126;e24-e28. DOI: 10.1542/peds.2009-0990.
  8. Simkin P. (2012) Singing to the baby before and after birth.  International Doula 19(3):30-31
  9. Simkin P. (2013) “There’s a Baby: A Children’s Film About New Babies.” PassionflowersProductions: Seattle.


Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Parenting an Infant , , , , , ,

Parents’ Singing to Fetus and Newborn Enhances Their Well-being, Parent-Infant Attachment, & Soothability: Part One

February 19th, 2013 by avatar

Regular contributor Penny Simkin shares her experiences with parents who sing to their baby in utero and then continue after birth and looks at what the research says about this practice in this two part blog piece.  Part two can be found here. Join me in reading about some unique situations that Penny shares as she explores this opportunity for parents to bond with their unborn child.  - Sharon Muza, Science & Sensibility Community Manager.


People have sung to their babies forever. Every culture has lullabies and children’s songs that are passed down through the generations. New ones are written and shared and the custom goes on –a rich part of the fabric of human civilization. These songs are designed to relax babies, calm their fears, or entertain and amuse them throughout childhood. As we have learned more about the life and capabilities of the fetus, we have realized that the fetus can hear clearly for months before birth, and also can discriminate sounds and develop preferences for some sounds over others. Furthermore, at birth, newborns respond to familiar sounds by becoming calm and orienting toward the source of the sound, and even indicate their preferences for familiar voices and words over the unfamiliar.

Newborn babies prefer their parents’ and other familiar voices over those of strangers (1), and they prefer hearing a story that their mother had read frequently in utero rather than an unfamiliar story or the familiar one read by someone other than their mother (2).  Fetuses hear, remember, have preferences, respond to, and discriminate among differences — in sounds, music, voices.

These exciting findings have inspired educators to advocate prenatal learning through recordings played through a mother’s abdomen (of languages, music, and other things). They have inspired birth activists and baby advocates to provide a safe enriching environment for the fetus. Advocates of prenatal bonding emphasize communication between parent and unborn child as a powerful way to strengthen the bond.

I’d like to offer my take on this phenomenon and urge everyone who works with expectant parents to tell them about some unique and heart-warming benefits of singing or reciting rhymes to their unborn babies.

I think my interest in parents singing to their babies prenatally began in the 1980s when I first read Michel Odent’s book, “Birth Reborn”(3). Odent is a French physician who has always been ahead of his time. He had a unique and original maternity care program at his hospital in Pithiviers, France. His book had a great influence on my understanding of normal birth, and the book is still worth reading today, along with all his subsequent ones. One lovely aspect of his program is particularly relevant to the topic of this blog post. The program included a weekly singing group at the hospital, attended by pregnant women, their partners, families with young babies, the midwives, and Odent himself. The group was led by an opera singer who believed singing to be important for fetuses, babies and those who care for them. Odent’s account inspired me to invite Jamie Shilling, a folk singer who had recently taken my birth class, to bring her guitar and her baby to my classes a half hour early each week and sing with the expectant parents. That went on very successfully for several class series, then the groups decided to combine and carry on in a monthly sing- along for expectant parents and new families, in a private home –Although the groups  eventually disbanded, they provided many parents with opportunities to sing together and connect with their babies and each other in relaxing and peaceful surroundings. A high point during that time was when Michel Odent came to Seattle to give a conference and he agreed to come to one of our sing-alongs. See the photo of Jamie leading the group of expectant and new parents, with Michel Odent and myself participating. He taught us the song, “Little Black Cat” in French.

© Penny Simkin

I couldn’t help but think during those times, how the unborn and new babies must love hearing their parents singing. Seeing the parents caressing the mother’s belly as they sang was heartwarming. That happened  in the mid- 1980s, when much research on the capabilities of the unborn and newborn baby was beginning to be published. Recalling those special gatherings, I have always suggested to my students in childbirth class that they sing to their unborn babies, or play their favorite recorded music, with the thought that the baby will remember it and be soothed by it after birth.

But it was one couple, whom I served as a birth doula, who took my suggestion to another level, and showed me much more about the value of singing to the unborn baby. They were having their second child, hoping for a VBAC. When they discovered that they were having a boy, they decided to give their baby the song, “Here Comes the Sun” and sang it to him often during pregnancy. The VBAC was not possible, and as the cesarean was underway, and the baby boy, crying lustily, was raised for the parents to see, the father began belting out the baby’s song. Though the mother didn’t have a strong voice under the circumstances, she also sang. The baby turned his head, turned his face right toward his father and calmed down while his father sang. Time stopped. As I looked around the operating room, I saw tears appear on the surgical masks.

It’s a moment I’ll never forget, and it was that event that taught me the value, not only of singing prenatally, but also, singing the same song every day. Not only does the baby hear his or her parents’ voices, not only does he or she hear music, but the baby also gets to know one song very well. Familiarity adds another feature to this concept, because we know that fetuses have memory and prefer the familiar. Think for a moment about what this might have meant to our cesarean-born baby –suddenly being removed from the warmth, wetness, and dimness of the womb with its mother’s reassuring heartbeat, into the cold bright noisy operating room. The baby’s transition to extrauterine life is hectic and full of new sensations. He cries reflexively, but perhaps also out of shock and discomfort. Then he hears something familiar – voices and music and the sounds of words that he has heard many times before – something he likes. He calms down, and seeks the source of this familiar song. Everyone present is moved by this gift to the baby from his parents.

I’ve become passionate about this idea as a way to enhance bonding between parents and babies, but also as a unique and very practical measure for soothing a fussing baby or a sick baby who can’t be held or breastfed. Please join me on Thursday, for Part Two on this topic when I will continue the discussion including research evidence that supports this concept: practical suggetions for childbirth professionals to share with expectant parents; and some very endearing film clips of families singing to their babies.


1. Brazelton B. Cramer B. (1991)The Earliest Relationship: Parents, Infants, and The Drama Of Early Attachment . Da Capo Press Cambridge, MA.

2. De Casper A. 1974, as described in Klaus M, Klaus P, Kennell J. 2000. Your Amazing Newborn. Da Capo Press, Cambridge, MA.

3. Odent M. 1984, Birth Reborn. Pantheon Books: New York 

Cesarean Birth, Childbirth Education, Doula Care, Guest Posts, Infant Attachment, Newborns, Parenting an Infant, Vaginal Birth After Cesarean (VBAC) , , , , , ,

Natural Childbirth – A Major Cause Of Posttraumatic Stress Syndrome?

August 16th, 2012 by avatar

By Penny Simkin, PT, CCE, CD(DONA)

In a two part series examining the recent research that stated that natural childbirth is a major cause of  Posttraumatic Stress Disorder,  our guest bloggers, Penny Simkin and Dr. David White, look at how the media may be sensationalizing the topic and reviews the published article to help understand more about what the research revealed.  Enjoy this blog post and the second part on Tuesday, August 21 to gain great insight into the statements made by the researchers. – SM

It has happened again. Yet another study of a hot topic in maternity care – this time, “natural childbirth,” which the authors define as “childbirth without an analgesia or without an epidural” – has been picked up by online and print media, and passed on to their audiences, with twists sensationalizing the material and adding fuel to the belief that natural childbirth is traumatic. Such articles bear provocative titles or subtitles, such as “Natural Births a Major Cause of PTSD”; “Having a Baby Like Being in a Terror Attack”; and “Is Natural Birth Connected with Post-Traumatic Stress in New Moms?”  Additionally, social media sites have begun discussing these frightening reports, most of which do not accurately present the study findings.

photo licensed under creative commons by megyarsh

The study causing the stir is “Postpartum Post-Traumatic Stress Disorder symptoms:  The Uninvited Birth Companion” (1), which was published in the Israel Medical Association Journal in June, 2012 but was picked up and disseminated widely only in early August. There are two major problems with this study:

  1. The misinformation and selective reporting by the media (it was attention from the media that led to my seeking the original paper to confirm the accuracy of the media statements; and
  2. The quality of the study itself (from design to interpretation of the findings to its validity).

In today’s blog post (part one of a two part series on this research article,) I will try to clarify some of the misinformation published in the media and analyze the harm done by these reports.  In part two, to be published on Science & Sensibility next Tuesday, David White, MD, masterfully analyzes deficiencies with the study itself.

At the beginning of the study, 102 women (a convenience sample) volunteered to participate in two surveys – one given within the first two to four days after birth and another at one month after birth. 89 subjects completed both surveys and were included in the results. The purposes of the surveys were to detect the prevalence of Posttraumatic Stress Disorder(PTSD,) and to identify associated risk factors before, during, and after birth. Because of the small sample size inconsistency in both reported numbers and terminology, and other factors (to be discussed in Part Two), any conclusions should be viewed with skepticism about the study’s external validity and applicability beyond the group studied.

And yet, despite these issues, the big media push has thrust this study into the limelight, giving it much more visibility and influence than it deserves. Most of the media accounts that I have read emphasize the finding that natural childbirth (meaning vaginal birth without pain medications) was the major cause of PTSD. In this study, there was an extremely high rate of cesarean birth (53%). Another finding reported by the media was that being accompanied during labor had no impact on the rate of PTSD. Neither of these findings was accompanied by statistical evidence.  These and other findings of the Israeli study are contrary to those of numerous other studies and reviews of satisfaction with childbirth, PTSD after childbirth, and the role of pain vs suffering during labor (2-4). Close examination of the details of the Israeli study design and reporting is called for, even though the damage has already been done by the media. Please see Part Two of this blog on Tuesday for this careful analysis.

Participants were questioned about the prevalence of PTSD symptoms after birth, and also about the presence of pre-pregnancy, intrapartum, and postpartum factors that are known to be associated with post-birth PTSD. Natural birth was highlighted by the media because of the report that 80% of the 7 women who developed PTSD (5 women) did not receive pain medication. In fact, many media reports state that these women either chose or opted for natural childbirth without pain relief. On careful inspection of the original paper, nowhere does it state that the women chose natural birth, but rather that “… fewer women who developed PTSD symptoms received an epidural and there was a great incidence of PTSD symptoms in women who did not receive an epidural.” It is possible that an epidural was not available to the women (which could be traumatizing if they had wished to have one).

Furthermore, these women had numerous other factors that are associated with PTSD. Before accepting natural birth as the major cause of PTSD after childbirth, please check the table below for these other factors, which were as prevalent, or nearly so, as lack of pain relief as a cause of PTSD. As you can see, for example, 80 percent of the women with PTSD also had discomfort with being undressed; previous mental health problems in previous pregnancy or postpartum; and complications, emotional crises, and high fear of childbirth in their current pregnancy.  All these factors have been reported in many studies to be instrumental in the development of PTSD (2-4).

Selected PTSD Risk Factors (with large differences in incidence between the two groups)

Existing before the study pregnancy P Value PTSD (n=7) No PTSD (n=82)
Psychiatric or psychological treatment P=0.157 60% (n=4) 29.8% (n=24)
Body image (uncomfortable in undressed state) P=0.014 80% (n=4) 27.7% (n= 22)
Existing in previous pregnancies      
Traumatic birth experience p=0.012 60% (n=4) 15.5% (n= 12)
Sadness, blues, or anxiety during or after pregnancy p=0.038 80% (n=4) 33% (n= 26)
Existing in current pregnancy      
Complications during p= 0.016 80% (n=4) 28.6% (n=25)
Emotional crises during p= 0.06 80% (n=4) 23.8% (n=21)
High fear of childbirth p= 0.021 80% (n=4) 30% (n= 27)
“A significantly smaller number of women who developed PTSD received analgesia during delivery compared to the control group” * p=0.000 No numbers or % given No numbers  or % given
Mothers’ Feelings in Labor & Birth     No PTSD (n=80)
Felt danger to their life or health p=0.001 71.4% (n=5) 20.7% (n=17)
Mild discomfort with undressed state p=0.029p=0.029 57.1% (n=4) 87.7% (n= 70)
Major discomfort with undressed state 42.9% (n=3) 12.3% (n= 10)
Support during labor      
No relationship between PTSD and being accompanied by someone or the extent of support received. No numbers or percentages were given.

*  This statement was all that was given to support “evidence” of natural birth as a cause for PTSD.

In spite of the flaws of this study, the authors offered some valuable conclusions, pointing out “the importance of inquiring about previous pregnancy and birthing experiences and the need to identify at-risk populations and increase awareness of the disorder.” Despite the shortcomings of their study, this advice is on target, as has been confirmed over and over again in the literature on traumatic birth.

In conclusion, this study was given much more publicity than it deserves, and as such has done more harm than good in understanding PTSD after childbirth. Our lesson: Recognize that many media outlets look for sensational and shocking material to attract readers, and will manufacture it if it doesn’t exist. Go to the source and think for yourself.

As educators and  birth professionals, how do you deal with students, clients and patients sharing what they read in the media, that may have been sensationalized?  What is your response?  Have you had to field questions about this recent study?  How do you respond?  Did you come to your own conclusions about this study?  Please come back on Tuesday to read a wonderful review of this research by Dr. David White and continue the discussion. – SM


1. Polachek I, Harari L H, Baum M, Strous RD, (2012) Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion. Israel Medical Association Journal 14: 347-353

2. Alcorn K L,  O’Donovan A, Patrick J C, Creedy D and Devilly G J. (2010). A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychological Medicine, 40, pp 1849-1859 doi:10.1017/S0033291709992224

3. Alder J, Breitinger G, Granado C, Fornaro I, et al. 2011. Antenatal psychobiological predictors of psychological response to childbirth. Journal of the American Psychiatric Nurses Association 17(6): 417-425. doi: 10.1177/1078390311426454

4. Simkin P, Hull K. 2011 Pain, Suffering and Trauma in the Perinatal Period. Journal of Perinatal Education 20(3): 166-175.

For more information visit the PATTCh Resource Guide.

About Penny Simkin

Penny Simkin is a physical therapist, childbirth educator, doula, and birth counselor. She is author or co-author of many books and articles on maternity related topics for both professionals and the public. She is a co-founder of DONA International, and of PATTCh (Prevention and Treatment of Traumatic Childbirth), and is also a member of the Editorial Board of the journal, Birth.

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Social Media, Uncategorized , , , , , , , , , , , ,

Part 2: Pain, Suffering, and Trauma in Labor and Subsequent Post-Traumatic Stress Disorder: Practical Suggestions to Prevent PTSD After Childbirth

February 28th, 2011 by avatar

[Editor's note:  This is part two of Ms. Simkin's post on childbirth-related Post Traumatic Stress Disorder.  The post is long and detailed--every word worth reading.  Set aside ample time to read this article: such that devouring, versus skimming, might be accomplished.  Birthing mothers & their birth partners, doulas, childbirth educators, L&D staff and maternity care providers will ALL benefit from the recommendations provided below.  To read part one of the post, go here.]

With Part 2 of this blog post, I’d like to move toward practical applications of the research findings on variables associated with traumatic birth and PTSD, as described in Part 1. Here is a list of suggestions (much more lengthy that I originally anticipated –Sorry!) for caregivers, doulas and childbirth educators, designed to prevent or minimize traumatic childbirth and subsequent PTSE of PTSD. These include suggestions for before, during and after childbirth.

Checklist for before labor:

Identify the woman’s issues or fears relating to childbirth.

The caregiver should elicit a psychosocial and medical history from the woman, and if there is evidence of previous unresolved trauma, discuss and strategize a course of care that maximizes her feelings of being supported, listened to, and in control of what is done to her, and minimizes the likelihood of loneliness, disrespect, and excessive pain. (1, 2)

The unique non-clinical relationship between doula and client requires that doulas do not ask specific questions regarding the woman’s psychosocial and medical history; rather, an open-ended question such as “Do you have any issues, concerns or fears that you’d like to tell me to help me provide better care for you?” The woman then has the option of whether or not to disclose sensitive issues. Many doulas, however, can recognize strong emotions without knowing specifics. The doula tries to be sensitive and accommodating without discussing her client’s anxiety directly.

Childbirth educators, rather than asking their groups about their issues, may find it more appropriate to discuss the potential effects of anxiety or old trauma on women’s experiences of labor, and to provide resources: books, referrals to support groups or counselors (possibly including the educator herself, if she can provide counseling) that can be helpful. Caution: If offering her services for counseling, the educator may be perceived as having a conflict of interest in raising these issues. To avoid such a conflict, I advise against charging a fee (beyond the class fee) for counseling one’s students, or to avoid mentioning herself as a resource.

The purposes of counseling for a woman with negative feelings about childbirth or maternity care are to help her clarify and address these feelings and strategize ways to 1) reduce their negative impact (at least), or 2) prevent further suffering or retraumatization, and 3) even result in empowerment and healing for the woman. (3) In fact, I feel there’s a great need to increase the numbers of birth counselors – people with a deep knowledge of birth and its accompanying emotions; maternity care practices and local options; excellent communication skills; and an understanding of trauma, PTSD, and other mood disorders relating to childbearing.  Wise childbirth educators and doulas with good communication skills should consider expanding their roles in this direction, along with nurses and midwives who have the time and skills to provide such counseling.

Recommend that the woman/couple learn about labor, maternity care practices, and master coping techniques for labor.

Childbirth classes that emphasize these elements, especially when they assist women and couples in personalizing their preferences and ways of coping with pain and stress, can take many surprises out of labor and empower parents to participate in their care and help themselves deal with pain and stress, whether with or without pain medications or other interventions.(4)

Recommend a Birth Plan:

A birth plan is a document that describes the woman’s personal values, preferences, emotional needs or anxieties regarding her child’s birth and her maternity care. It is most useful if it is the result of collaborative discussion between the woman and her caregiver, and if it is placed in the woman’s medical chart to be accessible for all who are involved in her care. (5) Usually, in hospitals where there is a spirit of cooperation and good will between clients and staff, birth plans are easily accommodated.  Sometimes, as in some cases of previous trauma or other adverse events, a woman will have a greater need for special considerations than other women. If the effort is made with care planning to address those needs, the potential for a safe satisfying birth experience is great, without causing harm or overwork for the staff. For example, simple requests (such as having people knock and identify themselves before entering her room; limiting the number of routine vaginal exams to those that are necessary for a clinical decision; allowing departure from a routine such as forceful breath holding and straining for birth) require flexibility but are not dangerous. A woman is likely to feel respected and understood if the staff gives serious consideration to her requests. The birth plan should include her preferences for the use of pain medications, not only yes or no, but the degree of strength of her preferences (6)

Of course, in her birth plan (or another term instead of “plan” may be used), she should use polite and flexible language (couching her preferences in language such as “as long as the baby is okay,” “if no medical problems are apparent”). She might prepare a Plan A, for a smooth uncomplicated labor, and a Plan B, for unexpected twists that make intervention necessary. A birth plan allows everyone to be on the same page, and ensures that the woman has a voice in her care, even when she is in the throes of labor. Childbirth educators and doulas have a responsibility to guide parents in the language and options included in the birth plan to maximize the likelihood that the plan will be well-received, while still reflecting her needs and wishes. If prenatal discussions indicate the birth is unrealistic or unreasonable, there is opportunity to discuss, clarify, and settle  the problems before labor, when it’s too late.

During labor:

Those caring for laboring women should remind themselves that the birth experience is a long-term memory (7) that can be devastating, negative, depressing, acceptable, positive, empowering, ecstatic, or orgasmic.

The difference between negative and positive depends not only on a healthy outcome, but a process in which she was respected, nurtured, and aided. In a study that I published years ago, on the long-term impact of a woman’s birth experience, I found that the most influential element in women’s satisfaction (high or low) with their birth experience 15 to 20 years later is how they remember being cared for by their clinical care providers (8), In fact, it was that study that motivated me to do what I could to ensure that women receive the kind of care that will give them lifelong satisfaction with their birth experiences. The answer became the doula.

“How will she remember this?” is a question that everyone who is with a laboring woman should ask him or herself periodically in labor, and then be guided by the answer to say or do things that will contribute to a good memory.

The doula:

The research findings of the benefits of the doula are well-known; in fact, a newly updated Cochrane Review of the benefits of doulas once again demonstrates the unique contribution of continuous support by a doula in improving numerous birth outcomes (See press release at http://www.childbirthconnection.org/pdfs/continuous_support_release_2-11.pdf and the full review with a summary at www.childbirthconnection.org/laborsupportreview/ (9). Besides the benefits reported in the Cochrane Review, I’d like to suggest a benefit that doulas may confer when traumatic birth is occurring: the doula’s care may be instrumental in preventing a traumatic birth from developing into PTSD. Czarnocka and Slade found with their study on normal births, 24% of the women had Post-traumatic Stress Effects (PTSE) and 3% had the full syndrome of PTSD.(10) (See Part 1 of this blog post for an explanation of the difference between PTSD and PTSE). They found that the women with PTSD were more likely to have felt unsupported and out of control than those who had PTSE. PTSE is far less serious that PTSD in terms of duration and spontaneous recovery.

Ironically, doulas are often traumatized by what they witness in birth settings where individualized care and low intervention rates for normal birth are not emphasized or supported. (11) They feel frustrated, demoralized or burned out, especially when their clients who had originally expressed a preference for minimal intervention, seem oblivious to the departure from their stated preferences and even grateful to the doctor who “saved their baby” after unnecessary interventions (which the woman had not wanted in the first place) led to the need for a cesarean. The woman has a traumatic birth, but later seems okay with everything that happened and doesn’t seem to have many serious leftover trauma symptoms (PTSE). I feel certain that in some of these cases of PTSE, the doula, by remaining with the woman, nurturing and helping her endure the physical helplessness, the fear and worry for her baby and herself, may have provided the positive factors identified by Czarnocka and Slade that protected her from PTSD. Prevention of PTSD is a worthy goal for a doula when birth is traumatic. (12)

Code word to prevent suffering:

No one wants a woman to suffer during labor. On the other hand, no supportive person wants a woman to have pain medication that she had hoped to avoid. A previously agreed-upon “code word” provides a safety net for a woman who is highly motivated to have an unmedicated birth. She says her code word only when she feels that she cannot go on without medical pain relief. The code word frees the woman to complain, vocalize, cry, and even to ask for medications, but her support team knows to continue their pep talks and encourage her to continue, and suggest some other coping techniques. However, if she says her code word, her team quits all efforts to help her continue without pain medications and turns to helping her get them. (13)

Why is a code word better than continuing to help her cope without medications when a woman (who had felt strongly about avoiding them) says she can’t go on, or vocalizes her pain loudly? It’s because some women cope better if they can express their pain than to have to act as if it doesn’t hurt. It also guides the team much more clearly than her behavior. As one woman said, “I shouted the pain down!” It’s really important for the nurse to know and understand the purpose of the code word, or she’ll feel the team is being cruel. If a supporter wonders if the woman forgot her code word, he or she can remind the woman, “You have a code word, you know.” One woman, when reminded, asked herself, “Am I suffering?” She decided she wasn’t, and went on to have a natural birth.

Of course, a code word is unnecessary if the woman plans to use an epidural.

Pain Rating Scale and Coping Scale:

All hospitals use a Pain Intensity Scale to measure patients’ (including laboring women’s) pain. See illustration of the Pain Intensity Scale. The goal, of course, is to ensure that no one suffers. The scale doesn’t rate suffering, however, since pain and suffering are not the same. (See Part 1 of this blog post.) Much more important is the woman’s ability to cope. See the illustration of the Pain Coping Scale. If she rates her pain at 8 (very high) and her coping is also rated very high, she’s not suffering. If pain is at 8 and coping is at 2, she could be suffering, and obviously needs attention, assistance, and very likely, pain medication.

Assessing a woman’s coping is done differently than assessing her pain. Rather than asking her to rate her coping on a scale of 10 (coping most easily) to 0 (total inability to cope), the supporter observes her behavior for the 3 Rs: Relaxation (between, if not during, contractions); Rhythm (in movements, breathing, moaning) and Ritual (coping with the same rhythmic activity for many contractions in a row). If she does not maintain the 3 Rs, she might very well suffer and feel traumatized by her labor. (14)


Pain Coping Scale: 10 to 0

A second way to assess coping is to ask the woman, after a contraction, “What was going through your mind during that contraction?” If her answer focuses on positive thoughts, or helpful activities, she is coping. If she focuses on how long or difficult it is, or how tired or discouraged, or how much pain she feels, she is not coping well and may be suffering. (15)

Intensive labor support may help her cope better and keep her from suffering, but pain medication may be the best way to relieve unmanageable pain that causes suffering. Help her obtain effective pain relief, whether it is pharmacological or non-pharmacological, according to her prior wishes and the present circumstances.

Recognize that if she has an epidural, she still needs emotional support and assistance with measures to enhance labor progress and effective pushing.

The absence of pain, usually accomplished so effectively by the epidural, does not mean absence of suffering. Nurses and caregivers in hospitals with high epidural rates are likely to make comments like, “There’s no need to suffer;” “You don’t have to be a martyr;” “There’s nothing to prove here.” With this assumption that pain and suffering are the same, once the pain is eliminated, the woman’s emotional needs are often neglected. In their classic study of pain, coping and distress in labor, with and without epidurals, Wuitchik and colleagues found, “With epidurals, pain levels were reduced or eliminated. Despite having virtually no pain, these women also engaged in increased distress-related thought during active labor. The balance of coping and distress-related thought for women with epidurals was virtually identical to that of women with no analgesia.” (16)

What are women distressed about when they have no pain? Wuitchik and colleagues named many things (and I have added some that I have witnessed), including: the length of labor; numbness; side effects such as itching and nausea; being left alone by supporters when she was “comfortable;” helplessness; passivity; worries over the baby’s well-being (especially with the sudden and dramatic reactions of staff when the mother’s blood pressure and fetal heart rates dropped); or feeling incompetent (when unable to push effectively despite loud directions to push long and hard).

The point is that women may suffer even if they have no pain, and their needs for continuing companionship, reassurance, kind treatment, assistance with position changes and pushing, attention to their discomforts and their emotional state, remain as important to the woman’s satisfaction and positive long-term memory as they are to the unmedicated woman. (17)

Take note if any variables occur during labor that are associated with traumatic births and PTSE (explained in Part 1 of this blog).

Warning signs of potential PTSE include feeling: angry (blaming others, alone, unsupported, helpless, overwhelmed, or out of control; also panicking, dissociating, giving up, feeling hopeless and as if she can’t go on (“mental defeat”). If she exhibits some of these signs, her caregiver, doula, and others should do as much as possible to prevent the trauma from becoming PTSD later (remaining close to her, reassuring her when possible, helping her keep a rhythm through the tough times, explaining what’s happening and why, holding her, making eye contact and talking to her in a kind firm confident tone of voice). The point is to help her maintain some sense that she is not totally alone, out of control, and overwhelmed.

After the Birth

Seeds of accomplishment

Before leaving the birth, a few specific positive and complimentary words from the “expert,” her doctor midwife or nurse, will remain in her mind, as she ruminates on her traumatic birth. “I was so impressed when you said you wanted to try waling when the labor had stalled for so long;” or “when you said you wanted to push a little longer;” or “when you realized that we had to get the baby out right away, and you said, ‘do what you have to do.’”

Anticipatory guidance for after birth.

When her labor and birth were traumatic, it is wise for the caregiver and her team to

1)      Acknowledge it openly: “You certainly did your part. I just wish it had gone more as you had hoped.”

2)      Anticipate some ways she might feel later, for example, she may find herself thinking a lot about the birth and recalling her feelings at the time.

3)      Give guidance on what to do: she can call her care provider, doula, childbirth educator, a good friend, or a counselor to review and debrief the experience (3, 18, 19, 20, 21). This cannot be rushed and the counselor (caregiver, doula, or other) should be available when the woman is ready to discuss it.

1.      Books (22, 23, 24) articles (surf the web!), and  Internet support groups may be helpful: Check the following:

http://www.birthtraumaassociation.org.uk/; http://solaceformothers.org/mothers-forum.html; http://www.tabs.org.nz/.

4)      Believe the woman when she says her birth was traumatic, and accept her perceptions of the events before clarifying or correcting misinterpretations. Help her reframe the event more positively, if possible, or suggest therapeutic steps to recover from the trauma. If PTSD does result, a referral should be made to a trauma psychotherapist, preferably one with experience with maternal mental health issues.

In conclusion, this is a reminder that traumatic childbirth is all too common, but with personalized sensitive care, much birth trauma can be avoided. If birth is traumatic for the woman, there are steps that can be taken before, during, and after childbirth to help ensure that the trauma does not become Post-Traumatic Stress Disorder. In fact, processing a traumatic birth experience can even provide an opportunity to heal and thrive afterwards.

This blog post series will be featured in the Fall 2011 issue of the Journal of Perinatal Education.  For references, please contact Ms. Simkin directly at: penny@pennysimkin.com or reference the JPE issue:  Summer 2011 Volume 20, Number 3.

Posted by:  Penny Simkin, PT, CCE, CD(DONA)

Doula Care, Patient Advocacy, Perinatal Mood Disorders, Practice Guidelines, PTSD, Research, Science & Sensibility , , , , , , , , , , , , ,

Pain, Suffering, and Trauma in Labor and Subsequent Post-Traumatic Stress Disorder: First of Two Posts by Penny Simkin, PT, CCE, CD(DONA)

February 15th, 2011 by avatar

Science & Sensibility welcomes new contributor, Penny Simkin, PT, CCE, CD(DONA).  Thank you for sharing your decades-long experience and expertise with us!

After the health of mother and baby, labor pain is the greatest concern of women, their partners, and their caregivers. Nurses and doctors promise little or no pain when their medications are used, and feel frustrated and disappointed if a woman has pain. Most are also extremely uncomfortable with her expressions of pain during labor—moans, crying, tension, frustration – because they don’t know how to help her, except to give her medication.

An enormous industry exists in North America to manufacture and safely deliver pain relieving medications for labor. Hospital maternity departments are designed with elimination of pain as a primary consideration, complete with numerous interventions and protocols to keep the pain management medications from causing serious harm. When staff believe that labor pain equals suffering, they convey that belief to the woman and her partner, and, instead of offering support and guidance for comfort, they offer pain medication. If that’s the only option, women will grasp for it.

This brings me to the topic of my blog post today – Pain, Suffering, and Trauma in Labor.

Definitions of Pain and Suffering
If we check the definitions of “pain” and “suffering” in lay dictionaries, the two are often offered as synonyms of one another, which helps explain the fear of labor pain. It’s a fear of suffering. But if we consult the scientific literature, there is a distinction among pain, suffering and trauma. As described in Lowe’s fine paper on the nature of labor pain (1), pain has been defined as, “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (2) The emphasis is on the physical origins of pain.

Lowe also points out that “suffering,” can be distinguished from pain, in that by definition, it describes negative emotional reactions, and includes any of these: perceived threat to body and/or psyche; helplessness and  loss of control; distress; inability to cope with the distressing situation; fear of death of mother or baby. If we think about it, one can have pain without suffering and suffering without pain. We can all recall times when we have been in pain, but did not fear damage or death to ourselves or others, nor did we feel unable to cope with the pain. For many people, athletic effort, recovery from planned surgery, dental work, and labor are painful but these people do not suffer with them. This is because the person has enough modifiers (knowledge, attention to other matters or goals, companionship, reassurance, touch, self-help measures, feelings of safety and other positive factors) to keep her from interpreting the experience as painful. All pain is not suffering.

By the same token, I’m sure we can recall times when we have suffered without pain. Acute worry or anguish about oneself or a loved one, death of a loved one, cruel or insensitive treatment, deep shame, extreme fear, loneliness, depression, and other negative emotions do not necessarily include real or potential physical damage, but certainly cause suffering. Therefore, all suffering is not due to pain. In fact, it is these negative modifiers that turn labor pain into suffering.

Of course, the goal of childbirth education has always been to reduce the negative modifiers, and increase the positive ones. The goal of anesthesiology has been to remove awareness of pain, in the assumption that when there is little or no pain, there will be no suffering. I’ll get back to that point later in Part 2 of this blog.

Suffering and Trauma
According to the American Psychiatric Association, the definition of trauma comes very close to the definition of suffering. “Trauma” involves experiencing or witnessing an event in which there is actual or perceived death or serious injury, or threat to the physical integrity of self or others, and/or the person’s response included fear, helplessness, or horror. (3)  Neither suffering nor trauma necessarily includes actual physical damage, although it may do so.

One’s perception of the event is what defines it as traumatic or not. As it pertains to childbirth, “Birth trauma is in the eye of the beholder” (4), and whether others would agree is irrelevant to the diagnosis.

Birth trauma and Post-Traumatic Stress Disorder (PTSD) after childbirth
A traumatic birth includes suffering and may lead to PTSD, which (according to the APA) means that the sufferer has at least 3 of the following symptoms that continue for at least one month:

  • nightmares
  • flashbacks
  • fears of recurrence
  • staying away from the people or location involved
  • avoiding circumstances in which, it can happen again
  • amnesia
  • emotional numbing
  • panic attacks
  • emotional distress

One national survey found that 18% of almost 1000 new mothers (up to 18 months after childbirth) reported traumatic births, as assessed by the PTSD Symptom Scale, a highly respected diagnostic tool. Half of these women (9% of the sample) had high enough scores to be diagnosed with PTSD after childbirth. (5)

Other smaller surveys (using women’s reports as the criteria for diagnosis) have found that between 25% and 33% of women report that their births were traumatic. Of these, between 12% and 24% developed Post-Traumatic Stress Disorder (PTSD). In other words, between 3% and 9% of all women surveyed developed PTSD after Childbirth.(6–9)

As we can see, every woman who has a traumatic birth does not go on to develop the full syndrome of PTSD. If they have fewer symptoms than the three or more required for the diagnosis, they may be described as having PTS Effects (PTSE). Though disturbing, the women are more likely to recover spontaneously over time than those with PTSD. The question of why some women get PTSD and others do not is intriguing and multifactorial: the propensity to develop post birth PTSD has to do with how they felt they were treated in labor; whether they felt in control; whether they panicked or felt angry during labor; whether they dissociated; whether they suffered “mental defeat;” (that is they gave up, feeling overwhelmed, hopeless and as if they couldn’t go on) (9, 10). Another risk factor for developing birth related PTSD  is having a history of unresolved physical, sexual and/or emotional trauma from earlier in their lives.  Even though unresolved previous trauma is unlikely to be healed during pregnancy, most of the other variables associated with PTSD can be prevented “through care in labor that enhances perceptions of control and support” (9).

In Part 2 of this blog post, I will suggest practical ways to apply what we know about the risk factors for childbirth-related PTSD, and how we can address these  before, during, and after childbirth.  I will discuss prevention and reduction strategies which can collectively reduce the likelihood of traumatic childbirth and subsequent PTSD.

This blog post series will be featured in the Fall 2011 issue of the Journal of Perinatal Education.  For references, please contact Ms. Simkin directly at: penny@pennysimkin.com or reference the JPE issue:  Summer 2011 Volume 20, Number 3.


Post By: Penny Simkin, PT, CCE, CD(DONA)

Doula Care, Healthy Birth Practices, Healthy Care Practices, Patient Advocacy, Perinatal Mood Disorders, PTSD, Science & Sensibility, Uncategorized , , , , ,