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The Roadmap of Labor: A Framework for Teaching About Normal Labor

September 2nd, 2014 by avatar

By Penny Simkin, PT

Regular contributor, Penny Simkin developed the roadmap of labor as a teaching tool.  Today, Penny shares how she uses the roadmap of labor to help families in her childbirth classes to understand normal labor from a physiological standpoint. She hopes that her students will take away an understanding of comfort and coping mechanisms along with recognizing the emotions a mother might be experiencing and how a partner can help with both the physical and emotional aspects. Penny is one of the Plenary Speakers at the upcoming Lamaze International/DONA International Confluence scheduled for later this month in Kansas City, MO.  Read how Penny, a master childbirth educator, with this handy tool, helps parents understand what to expect  during labor and birth. – Sharon Muza, Community Manager, Science & Sensibility

Introduction

© Sarah Sweetmans

© Sarah Sweetmans

Childbirth educators strive to provide timely, accurate, woman-centered information. We adapt our content and teaching methods to the time allowed, and the variety of learning styles, educational levels and cultural backgrounds of our students. We hope to build trust in the normal birth process, and instill the confidence and competence necessary for parents to meet the challenges of childbirth, and also to communicate effectively with their maternity caregivers.

In this paper I describe a teaching aid, the roadmap of labor, and some ideas to help guide parents through normal childbirth, from early labor to active labor, transition, and the resting, descent and crowning-to-birth phases of the second stage. The discussion of each stage and phase includes what occurs, women’s and partners’ common emotional reactions, and advice on comfort measures and ways to work together to accomplish a safe and satisfying birth.

I do not describe how I teach about routine or indicated interventions, complications, pain medications, or surgical birth. Aside from space limitations, the real reason lies in my firm belief that when expectant parents appreciate the pure unaltered (and elegant!) physiological process of labor, they have more confidence that birth usually goes well, and they may feel reluctant to bypass it (with induction or cesarean) or alter it unnecessarily. Normal labor becomes the clear standard against which to assess the benefits and risks of specific interventions and the circumstances that increase or decrease their desirability.

If I combined the discussion of straightforward labor with complications and common procedures (along with their risks, benefits, and alternatives), parents would have a fragmented and confused perception of childbirth and an almost impossible burden of separating normal from abnormal, and elective from indicated procedures. All these topics must be covered, however, if parents are to participate in their care, whether labor is straightforward or not. Therefore I teach these topics in subsequent classes, using normal birth as the reference point. I also follow this approach in some other writings.1,2

Initiation of labor, the six ways 
to progress and signs of labor

There are some key concepts that childbirth educators can use to raise parents’ awareness and appreciation of events of late pregnancy and normal birth and how they can help the process flow smoothly. Parents need to understand these concepts well, so they can use the roadmap of labor to best advantage, and play a more confident and active role in labor.

For example, before introducing the roadmap, the teacher should inform parents about the hormonally- orchestrated processes in late pregnancy that prepare for birth, breastfeeding, and mutual mother-infant attachment. This is important because teachers face two common challenges: first, parents’ impatience to end the pregnancy due to discomfort, fatigue and eagerness to hold their baby; and second, the possibility of a long, discouraging pre-labor phase.

These challenges make parents more accepting of induction or vulnerable to the belief that there is something wrong. Parents need to understand that labor normally begins only when all of the following occur:

• The fetus is ready to thrive outside the uterus (breathing, suckling, maintaining body temperature, and more).
• The placenta has reached the point where it can no longer sustain the pregnancy.
• The uterus is ready to contract, open and expel the baby.
• The mother is ready to nourish and nurture her baby.

If parents understand that fetal maturity is essential in initiating the chain of events leading to labor, they may be more patient with the discomforts of late pregnancy, and less willing or anxious to induce labor without a medical reason.

The six ways to progress to a 
vaginal birth

Progress before and during labor and birth occurs in many ways, not simply cervical dilation and descent, which is what most people focus on. Labor unfolds gradually and includes six steps, four of which begin weeks before labor and involve the 
cervix. The cervix moves forward, ripens, effaces and then dilates. When parents understand that a long pre- or early labor is accomplishing necessary progress – preparing the cervix to dilate – they are less likely to become anxious or discouraged that nothing seems to be happening. The two other steps involve the fetus: the fetal head repositions during labor by flexing, rotating, and moulding to fit into the pelvis; and lastly, the fetus descends and is born.

Three categories of signs of labor

By placing these in the context of the six ways to progress, parents may be better able to recognize the differences between pre-labor (often called ‘false labor’) and labor.

Possible signs of labor

These include: nesting urge; soft bowel movements; abdominal cramping; and backache that causes restlessness. These may or may not continue to the clearer signs of labor and may be associated with early cervical changes.

Pre-labor signs

The most important of these is the first one:

  • Continuing ‘nonprogressing’ contractions (that is, over time,
the pattern remains the same; they do not become longer, stronger or
closer together)
  • Possible leaking of fluid from the vagina
  • Possible ‘show’ – bloody mucus discharge from the vagina

With these signs, the cervix is probably not dilating significantly, but is likely to be ripening and effacing (steps two and three of the six ways to progress).

Positive signs of labor

The most important of these is the first one:

  • Continuing, progressing contractions, i.e. contractions that become longer, stronger, and closer together (or at least two of those signs). These progressing contractions cause cervical dilation (steps four and five of the six ways to progress), which is the clinical definition of labor.
  • Spontaneous rupture of the membranes (SRM), especially with a gush of fluid. This happens before or at the onset of labor in about 8% of women at term.3 It most often happens late in labor. SRM is only a positive sign of labor 
in conjunction with continuing progressing contractions.

The roadmap of labor

I have created a visual guide to labor progress using the metaphor of a road map. It shows key labor landmarks, and appropriate activities and measures for comfort as labor progresses (see Figure 1).4 Parents can use it during labor as a reminder of where they are in the process and what to do. Teachers can use it as a tool for organized discussion of normal labor progress, and as a backdrop for discussing laboring women’s emotional reactions, and how partners or doulas may assist. Health professionals can use it to help parents identify where they are in labor, adjust their expectations and try appropriate comfort measures.

© Penny Simkin

© Penny Simkin

Normal labor pathway

The roadmap portrays three pathways. The main brick road represents normal labor and shows helpful actions, positions, and comforting techniques to use as labor progresses. The twists and turns in the brick road indicate that normal labor does not progress in a straight line; the large turns between three and five-to-six centimeters and between eight and ten centimeters indicate large emotional adjustments for the laboring woman, and present an opportunity to discuss emotional support and comfort measures for the partner or doula to use. After ten centimeters, the woman’s renewed energy and confidence are represented by the second wind sign. Along with discussion of emotional support and comfort measures, the teacher can offer perspective and practical advice for partners and doulas, to use both when the woman is coping well and when she feels challenged or distressed.

The roadmap provides a clear and effective way to teach about normal labor. It keeps the discussion focused purely on the physiological and psychological processes, without inserting discussions of pros and cons of interventions, complications, or usual policies and hospital practices that alter labor.

Image Source: © Sharon Muza

Image Source: © Sharon Muza

Once parents have a solid understanding of normal labor, the teacher can explain usual care practices and possible options for monitoring maternal and fetal well being during labor. She can also discuss labor variations or complications and treatments with medical (including pain medications), surgical or technological procedures. With this approach, parents are better equipped to discuss risks, benefits and alternatives, because they can distinguish situations and conditions that are more likely to benefit from the intervention from those in which the intervention is optional, unnecessary, or harmful.

Planned and spontaneous rituals

The normal labor road suggests measures to use for distraction, comfort, and progress. Distraction is desirable for as long as it helps. The Relax, Breathe, Focus sign reminds parents to use this pre-planned ritual for dealing with intensifying contractions when distraction is no longer possible. Parents need to rehearse these rituals in childbirth class (i.e. slow breathing, tension release, and constructive mental focus) and use them in early labor. They set the stage for the spontaneous rituals that emerge later in labor (as women enter active labor), when they realise they cannot control the contractions or continue their planned ritual, and give up their attempts to do so, though sometimes after a stressful struggle. Spontaneous rituals replace the planned ones. They are not planned in advance – they are almost instinctual – and almost always involve rhythmic activity through the contractions – breathing, moaning, swaying, stroking, rocking, or even letting rhythmic thoughts or phrases repeat like a mantra.

The three Rs

The spontaneous rituals usually involve the three Rs: relaxation (at least between contractions), rhythm, which is the most important, and ritual, the repetition of the same rhythmic activity for many contractions. In order to give herself over to spontaneous instinctual behavior, the woman needs to feel emotionally safe, uninhibited, accepted unconditionally by partner and staff, and to be mobile in order to find comfort.

The motto ‘Rhythm is everything’ means that if a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult. The rhythmic ritual keeps her from feeling totally overwhelmed. The goal is to keep her rhythm during contractions in the first stage. Once in second stage, however, rhythm is no longer the key. The woman becomes alert and her spirits are lifted. An involuntary urge to push usually takes over and guides her behavior.

The role of the partner in labor

The partner helps throughout labor, comforting the mother with food and drink, distraction, massage and pressure, assistance with positioning, and constant companionship. Sometimes a doula also accompanies them, providing continuing guidance, perspective, encouragement, and expertise with hands-on comfort measures, positions, and other techniques gained from her training and experience.2

The role of an effective birth partner includes being in the woman’s rhythm
– focusing on her and matching the rhythm of her vocalizations, breathing or movements – by swaying, stroking, moving hand or head, murmuring softly in her same rhythm. Then, if she has difficulty keeping her rhythm, and tenses, cries out or struggles – as frequently occurs in active labor or transition – her partner helps her get her rhythm back, by asking her to focus her eyes on their face or hand and follow their rhythmic movements. This is the take-charge routine, and is only used if the woman has lost her rhythm, is fearful, or feels she cannot go on. Partners who know about this are less likely to feel helpless, useless or frightened. Simple directions, given firmly, confidently, and kindly (‘look at me,’ or ‘look at my hand’), rhythmic hand or head movements, and ‘rhythm talk’ with each breath (murmuring, ‘Keep your rhythm, stay with me, that’s the way…‘) are immensely effective in helping the woman carry on through demanding contractions. During the second stage, rhythm is no longer important; now the partner encourages her bearing-down efforts and release of her pelvic floor, and also assists her with positions.

The motto “Rhythm is everything” means that if
 a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult.

The detour for back pain

A second pathway, a rocky, rough road, represents the more difficult ‘back labor’, which may be more painful, longer, or
more complicated than the normal labor pathway. Fetal malposition is one possible cause. The measures shown for back labor are twofold: reduce the back pain and alter the effects of gravity and pelvic shape to encourage the fetus’s movement into and through the pelvis. It helps a woman endure a prolonged or painful back labor if she and her partner use appropriate comfort measures, and if they know that dilation may be delayed while the baby’s head molds or rotates to fit through, or that changing gravity and pelvic shape may give the extra room that the baby needs to move into an optimal position.

The epidural highway

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

This third pathway represents a dramatically different road – smooth, angular, man- made, more comfortable – but it comes with extensive precautions and numerous procedures, monitors, and medications, which are necessary to keep the epidural safe. The woman adopts a passive role while the staff manage labor progress, and monitors the mother’s and fetus’s well being closely. The excellent pain relief and chance to sleep are the usual rewards. Discussion of how to work with an epidural in order to optimize the outcome is beyond the scope of the paper, but the basic principle is: treat the woman with an epidural as much as possible like a woman who does not have one! This essentially means,‘Keep her cool. Keep her moving. Keep her involved in the work of pushing her baby out. And don’t assume that if she has no pain, she has no distress! Do not leave her alone.’

Conclusion

The roadmap of labor provides a useful framework for teachers to explain the psychological and physiological processes of labor, and a variety of activities for comfort and labor progress for women and their partners to use. By focusing on the normal unaltered process, parents learn to separate the norm from the numerous interventions that alter the process, sometimes for the better, sometimes for the worse. The intention is to give them confidence that they can handle normal labor and to participate meaningfully in decision-making when interventions are suggested.

Do you use the roadmap of labor as a teaching tool in your childbirth classes or with your clients?  How do you use it?  I would love to hear the innovative ways that you have found to incorporate this valuable tool in your classes.  Please share with Penny and all of us in the comments section. – SM

References

1. Simkin P. Moving beyond the debate: a holistic approach to understanding and treating effects of neuraxial analgesia. Birth 2012;39(4):327-32.

2. Simkin P. The birth partner: a complete guide
to childbirth for dads, doulas, and all other labor companions. 4th edition Harvard Common Press; 2013.

3. Marowitz A, Jordan R. Midwifery management of prelabor rupture of membranes at term. J Midwifery Womens Health 2007;52(3):199-206.

4. Simkin P. Road map of labor. Childbirth Graphics; 2003. Available from: www.childbirthgraphics. com/index.php/penny-simkin-s-road-map-of- labor-interactive-display.html

About Penny Simkin

penny_simkinPenny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 11,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2008), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

Copyright © NCT 2014. This article first appeared in NCT’s Perspective journal, edition March 2014.   http://www.nct.org.uk/professional/research

2014 Confluence, Cesarean Birth, Childbirth Education, Continuing Education, Guest Posts , , , ,

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.

Conclusion

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.

References:

  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.

References:

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)
Delivery      
“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

Resources:

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 , , , , , , , , , , , , ,