Posts Tagged ‘Penny Simkin’

Applying the Health Belief Model in Your Role as a Birth Professional

June 4th, 2015 by avatar

HealthBeliefModelPart2Last Tuesday, in part one of this two part post series, Andrea Lythgoe explained the Health Belief Model in her blog post Understanding the Health Belief Model.  Andrea discussed the different components that make up this model.  As we learned, perception is key and there are several different ways that a family’s perception of their circumstances can influence their decision making.  Today on Science & Sensibility, Andrea discusses how the childbirth educator or other birth professional can use this knowledge about the Health Belief Model to structure conversations and activities that assist families in making important decisions about their maternity care. – Sharon Muza, Science & Sensibility Community Manager

So how does this Health Belief Model come into play with childbirth education? It is important to remember that as childbirth educators, our role is not to be manipulative and push families towards certain goals.  Our responsibility is to present evidence based information so that families can make decisions that feel right for them.Here are some approaches we can use that make use of this model when fostering decision making skills in the families that attend our classes:

Perceived Benefits

Childbirth educators can provide families with information about the benefits and risks of the choices they are considering, and introduce other options they might not have considered. For example, I frequently have families in my classes who are unhappy with their care provider. I can help the family understand the benefits of more clearly communicating their birth preferences with their care provider to make sure that the HCP is on board. I can point out that they may find switching to a different care provider or birth place potentially more compatible with their own preferences, and give them tools to explore, evaluate, and choose the option that feels right to them.

Perceived Barriers

Childbirth educators can carefully listen for and identify the barriers that families perceive exist. You may be able to correct misinformation that a family believes prevents them from making a change they wanted to make. Be a MythBuster! Proactively address and correct myths that might be perceived barriers for your students and clients.ApplyingHBM2

Perceived Seriousness

Childbirth educators can help families to recognize, investigate and  accurately understand the risks of choices they may encounter.  We can give them tools to discuss and understand the “culture of risk” so that they have an idea of the severity of potential interventions and side effects. This goes both ways, as we need to be careful to be honest and realistic about the information we present. Always provide evidence based information and steer clear of exaggeration, minimization and scare tactics.

Perceived Susceptibility

Susceptibility is the hardest one to address. As I mentioned in my earlier blog post, once a person has experienced a loss or complication – in themselves or a loved one – there is a loss of innocence, and it is difficult to get past the previous experience. They don’t need to be “talked out” of feeling susceptible, but childbirth educators can often help families navigate the fear they may feel. Validation of their fears, suggestions for coping with fears, and potentially referring to counseling are ways to assist families who may be paralyzed by fear. It is important to be aware of how your own experiences affect your approach to providing unbiased information to your students and clients.


Childbirth educators can do wonders for helping class members build their self-efficacy. One simple activity that I have found builds self-efficacy is to ask pregnant people to list two times in their life when they have achieved something that did not come easily, and two times they saw their partner do the same. They then share their lists with each other or even with the class. I ask them to describe to each other or write down the personal traits that helped them accomplish this difficult task.CaregiversMotto

Another way to build self-efficacy in your classes is to provide lots of opportunity for families to practice the skills and coping tools they may find helpful in labor, multiple times during their childbirth class, in a variety of situations. This repetition helps to build confidence in their ability to remember and use the techniques when they are in labor. You can build on techniques you’ve previously taught. If you taught a slow deep breathing technique last week, encourage pregnant people to practice it during later parts of their class when you teach massage or positions.

Cues to Action

As childbirth educators, we may be able to provide some cues to action. Giving families the assignment to prepare a birth plan before your next class can be one such cue to action. You can also help partners to learn to provide these cues to action as well. Reminders in labor to ask for time to make decisions can be a cue to review all their options and use the “BRAIN” tool to make decisions. As a childbirth educator, it is key to remember that you cannot force them take action, you can only provide the pregnant person and their partner with cues they can choose to act on – or not.


Having a good understanding of the perceptions and factors influencing families’ decision making can help us as childbirth educators and birth professionals to create effective classroom activities.  We can also use this information to improve communication and personal interactions with the families we work with. When childbirth educators can provide their students with tools for making the decisions that are best for them, families can move confidently through any decisions that they may face throughout the childbearing year and beyond.

In closing, it is always good to remember the Caregiver’s Motto taught by Penny Simkin:

 “A person  has a very good reason for…

…Feeling this way
…Behaving this way
…Saying these things
…Believing these things…”

How do you help the families that you work with to make decisions?  What activities do you find build self-efficacy and confidence in your classes?  How do you best apply the Health Belief model to your interactions with students and clients? Please share your experiences in the comments section. – SM

About Andrea Lythgoe

Andrea Lythgoe

Andrea Lythgoe

Andrea Lythgoe is a doula, hospital-based Lamaze childbirth educator, birth photographer, and former instructor at the Midwives College of Utah. She is the author of the website UnderstandingResearch.com where she aims to help those just beginning to read research to understand the language of research. Her interest in research started while attending the University of Utah, where she made ends meet by working on a large randomized controlled trial and earned a degree in community health. Andrea served on the Board of Directors for the Utah Doula Association for over 10 years. She lives and practices in the Salt Lake City, Utah area. Andrea can be reached through her website.




Childbirth Education, Guest Posts, Maternity Care , , , ,

Sarah Buckley’s “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” – A Review for Birth Educators and Doulas

January 13th, 2015 by avatar

by Penny Simkin, PT, CD(DONA)

Today, a long awaited report written by Dr. Sarah Buckley, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” is being released by Childbirth Connection. In this valuable report, Dr. Buckley gathers the most current research and provides the definitive guide for the role of hormones in normal, natural birth.  Esteemed childbirth educator, doula and author/filmmaker Penny Simkin has reviewed Dr. Buckley’s latest offering and shares today on Science & Sensibility how childbirth educators, doulas and other birth professionals can use this information to inform parents on how best to support the physiological process of childbirth.  In coordination with this research report, Dr. Buckley and Childbirth Connection are releasing a consumer booklet geared for families and consumers as well as other material, including infographics in support of this report.  On Thursday, Lamaze International Past President Michele Ondeck will share her interview with Dr. Buckley. In that interview,  S&S readers can get the full story directly from Dr. Buckley, on just what it took to create this remarkable tome. – Sharon Muza, Community Manager, Science & Sensibility.

© Childbirth Connection

© Childbirth Connection


For many of us who work in the maternity field, Sarah Buckley’s fine work is well-known. Her book, “Gentle Birth, Gentle Mothering” (Buckley, 2009) has provided scholarly and enlightening guidance on natural childbirth and early parenting for many years. Her 16 page paper, “Ecstatic Birth,” (Buckley, 2010) guides educators and doula trainers, who rely heavily on her explanations of hormonal physiology in childbearing, for teaching about labor physiology and psychology and the impact of care practices.

Her newest publication, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care,” (Buckley, 2015) is a gift to us all. It represents a massive scholarly effort, a review of all the related scientific literature on the topic. With 1141 references, most of which were published in recent years, Dr. Buckley’s overview provides the transparency to allow readers to trace her statements to the evidence on which they are based. She exercises caution in drawing concrete conclusions when the evidence is insufficient; she presents such information as theory (rather than fact), and points out when more research is necessary for concrete conclusions. The “theory” that undisturbed birth is safest and healthiest for most mothers and babies most of the time is impressively supported by her exhaustive review, as stated in the conclusion (Buckley, 2015):

“According to the evidence summarized in this report, the innate hormonal physiology of mothers and babies – when promoted, supported, and protected – has significant benefits for both during the critical transitions of labor, birth, and the early postpartum and newborn periods, likely extending into the future by optimizing breastfeeding and attachment. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes. Because of the possibility of enduring effects, including via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physiologic processes in childbearing.”

The Precautionary Principle, to which she refers, has been stated as follows:

“When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. . . . It (the activity) must also involve an examination of the full range of alternatives, including no action.” (Science and Environmental Health Network, 1998).

In other words, when applied to maternity care, The Precautionary Principle states that when a practice, action, or policy may raise threats of harm to mother, baby, or family, the burden of proof that it will result in more good than harm falls on those who wish to adopt it – the policy maker, caregiver, or administrator, not on the pregnant person.

© Sarah Buckley

© Sarah Buckley

What’s new in this document and how might you use it and apply it in your classroom or practice?

This document represents the “State of the Science” regarding hormonal physiology of childbirth (HPOC). It should be the starting point for consideration of proposed changes in maternity care management and education. The question, “How might this policy, practice, or new information impact the HPOC and subsequent outcomes for mother and/or baby?” should be asked and answered about both existing and proposed interventions.

Sarah Buckley has asked and answered this question, and reveals the unintended consequences of numerous widespread practices, including scheduled birth – induced labor or planned cesarean; disturbance and excessive stress during labor; synthetic oxytocin (Pitocin); opioids and epidural analgesia for labor pain; early separation of mother from infant or wrapping the infant in a blanket to be held (i.e., no skin-to-skin contact); breastmilk substitutes, and many more. All of these practices cause more harm than good, except in unusual or abnormal circumstances.

One of the greatest contributions of this book is showing that hormonal physiology is affected by virtually every intervention –major and minor — and understanding this is the key to appropriate maternity care. The topic is complex and not nearly fully understood, but Sarah Buckley has pulled together just about everything that is now known on this topic. If you’re a maternity care practitioner or student, who wants to approach the care you give from a physiological perspective, or want information on the impact of common interventions on the physiological process, it’s all here. If you’re a researcher interested in studying some aspect of HPOC, your literature search has already been done for you and you can discover the many areas that have been insufficiently studied and plan where to go from there.

If you’re a childbirth educator seeking to give accurate information to expectant parents about how normal childbirth unfolds and how it can be altered (for better or worse) with common procedures and medications, you can learn it here. If you’re a doula who wants to understand how your presence and actions may contribute to normalcy, you can learn it here. If you’re an expectant parent who wants to make choices that maintain or improve the pregnant person and infant’s well-being, you can learn it here or access the consumer guide.

Organization of the Chapters

This book, with its numerous references, sheer number of pages, level of detail and broad scope, may seem daunting at first. However, if you take some time to familiarize yourself with the layout of the book before plunging in, you will find that the material in each chapter is arranged so that readers can explore each topic at varying levels of detail.

The book begins with a very helpful 10 page executive summary of the contents. There are then two chapters introducing concepts relevant to HPOC, and on the physiologic vs. scheduled onset of birth (induction and planned cesarean birth). The 7 chapters are organized with topics and subtopics. The first paragraph beneath the headings for each topic or sub-topic briefly and clearly summarizes the information in that section in italics, so that you can skim each topic by reading only the italicized summary. If you wish to investigate some subtopics more deeply, you can read everything included on those topics. Each chapter also ends with a summary of the entire chapter. Chapters 3, 4, 5, and 6 (Chapter 3 — “Oxytocin;” 4 —“Beta-Endorphins;” 5 —“Epinephrine-Norepinephrine and Related Stress Hormones;” ; and 6 —“Prolactin”) follow the same outline of topics and subtopics.

Using Chapter 6 (“Prolactin”) as an example, here is the outline:

  • 6.1 Normal physiology of prolactin
    • 6.1.1 Introduction: Prolactin
    • 6.1.2 Prolactin in pregnancy
    • 6.1.3 Prolactin in labor and birth
    • 6.1.4 Prolactin after birth
  • 6.2 Maternity care practices that may impact the physiology of prolactin
    • 6.2.1 Possible impacts of maternity care provider and birth environment on prolactin
    • 6.2.2 Prostaglandins for cervical ripening and labor induction: possible impacts on prolactin
    • 6.2.3 Synthetic Oxytocin in labor for induction, augmentation, and postpartum care: possible impacts on prolactin
    • 6.2.4 Opioid analgesic drugs: possible impacts on physiology of prolactin
    • 6.2.5 Epidural analgesia: possible impacts on physiology of prolactin
    • 6.2.6 Cesarean section: possible impacts on physiology of prolactin
    • 6.2.7 Early separation of healthy mothers and newborns: possible impact on physiology of prolactin
  • 6.3 Summary of all findings on prolactin

For childbirth educators: how might we use this information to benefit our students?

I especially appreciate that Dr. Buckley begins every section with a description of the relevant physiology. In order to be truly effective, we educators should do the same in our classes, to ensure that our students understand how and when their care is consistent with physiological childbearing and when (and why) it is not. “’Physiological childbearing’ refers to childbearing conforming to healthy biological processes,” (Buckley, 2015, page 11) as opposed to what many might refer to as “medicalized childbearing,” in which the physiologic process is altered or replaced with interventions and medications.

© Childbirth Connection

© Childbirth Connection

Childbirth education should be designed to allay the pregnant person’s anxiety, not by avoiding mention of potentially troubling labor situations, or minimizing concerns mentioned by the students, but rather by giving realistic portrayals of birth, encouraging expression of feelings, and dealing with them by informing, reframing, desensitizing, and strategizing ways to handle troubling situations. Following is an example of how an educator might include hormonal physiology of childbearing to teach about one critical topic – Physiologic Onset of Labor, which is Lamaze International’s First Healthy Birth Practice.

Let labor begin on its own: How to teach from the standpoint of HPOC

Chapter 2 in HPOC , “Physiologic Onset of Labor and Scheduled Birth,” details the ‘highly complex orchestrated events that lead to full readiness for labor, birth and the critical postpartum transitions of mother and baby.” (Buckley, 2015). As educators, we should try to convey this information, in simplified form, to help our students appreciate the beauty and connectedness of the whole mother-baby dyad. They need to understand the consequences of interrupting the chain of events that usually result in optimal timing of birth. Most parents (and many caregivers as well) have no idea that the fetus determines the onset of labor. Nor do they know that fetal readiness for labor (including protection against hypoxia and readiness for newborn transitions after birth) is coordinated with preparation of the mother’s body for labor, breastfeeding and mother-infant attachment. Once students have some grasp of these processes, they appreciate and want to protect them from interruption or replacement by medical means. As we know, most inductions and many planned cesareans are done without medical reason (ACOG, 2014). Out of ignorance and/or misinformation from their caregivers, parents often agree or even ask for these procedures.

While many educators know and teach about the risks and benefits of induction and planned cesarean, they often don’t convey the physiology on which the benefits and risks are based. It’s all here in HPOC, and this information may inspire parents to question, seek alternatives or decline these procedures.

Over the years, I have wrestled with the challenge of conveying this information fairly simply and concisely, and now, with the help of Katie Rohs, developed a new animated PowerPoint slide, “The Events of Late Pregnancy” (Simkin, 2013) that I use in class. You may access this animated slide and accompanying discussion points/teacher guide here.© Penny Simkin

© Penny Simkin

This is just one example of how we may shift our focus as teachers to incorporate basic hormonal physiology as a starting point. Dr. Buckley gives us a solid understanding of what is known about the key role the endocrine system plays in orchestrating the whole childbearing process, and why we shouldn’t disrupt this elegant process without clear medical reasons. If we teachers and other birth workers incorporate this information in our practices and in our teaching, outcomes will improve.

“Hormonal Physiology of Childbearing” is surely the most extensive search ever done on this topic, and is a solid guide to learning this crucial information. Encyclopedic in its scope, and multi-layered in its depth, this book will be most useful as a reference text, rather than a book to read straight through. It is pretty dense reading, but when you have a question relating to reproductive physiology or the effects of interventions, you can search for well-explained answers. The evidence-based conclusions that Sarah Buckley has synthesized from an abundance of research (1141 references!) are authoritative and must be made accessible. This is truly “State of the Science” on Hormonal Physiology of Childbearing.


Typical maternity care today has departed so far from physiology that in many cases it causes more harm than good, as borne out by Dr. Buckley’s discussions throughout the book of the impact (i.e., unintended consequences) of common maternity care practices on hormonal physiology and mother-baby outcomes. Our job is to inform expectant parents of these things and help them translate information into preparedness and confident participation in their care. If we do our job well, our students will want to support, protect, and participate in the physiological process, which has yet to be improved upon. Parents and their babies will benefit! Our thanks should go out to Sarah Buckley and to Childbirth Connection for bringing this gift to us.

In conclusion, Sarah Buckley’s “Hormonal Physiology of Childbearing” is an impressive exploration of the major hormonal influences underlying all aspects of the labor and birth process. As we understand and incorporate the knowledge included in the book, the birth process will become safer, with effects lasting over the life span.


American College of Obstetricians and Gynecologists and Society of Maternal-Fetal Medicine, 2014. Safe Prevention of the Primary Cesarean Delivery. Obstetric Care Consensus Number 1. Obstet Gynecol ;123:693–711.

Buckley S. Ecstatic Birth. Nature’s Hormonal Blueprint for Labor. 2010. www.sarahbuckley.com

Buckley S. 2009, Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices. Celestial Arts, Berkeley

Buckley S. 2015. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. Childbirth Connection, New York

Science & Environmental Health Network. 1998. Wingspread Conference on the Precautionary Principle. Accessed Jan. 8, 2015, https://www.google.com/search?q=The+Precautionary+Principle&ie=utf-8&oe=utf-8.

Simkin P. 2013, Events of Late Pregnancy. Childbirth Education Handout and Slide Penny Simkin, Inc. Seattle. https://www.pennysimkin.com/events-powerpoint

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 13,000 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 (2013), 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.


Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Guest Posts, Healthy Birth Practices, Infant Attachment, Maternity Care, Medical Interventions, New Research, Newborns, Uncategorized , , , , ,

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


© 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.’


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


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 birth1. 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) , , , , , ,

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