“I was at a routine dental office visit a few weeks after my daughter was born. I remember being reclined in the chair, the bright overhead light and the scent of latex.  Images of surgical masks whipped through my mind.  Fear rushed through my body and I shook uncontrollably.  My body felt hollow and numb but also heavy and out of control.  In that moment I truly believed I was having another emergency c-section.”

This quote is from a woman who experienced a traumatic birth.  She is the mother of a beautiful baby and has had many moments of joy and connection, but also times of panic and fear.  “Mini movies” of her daughter’s birth play in her mind throughout the day.  She deleted the photos of her daughter in the NICU and she wants to disappear when her friends talk about pregnancy.  The birth didn’t end when her baby was born; it followed her from the hospital and it has interfered with many aspects of her life.

Research reveals that between 33-45% of women perceive their births to be traumatic. (Beck, 2013).  Birth trauma is defined as “an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant.  The birthing woman experiences intense fear, helplessness, loss of control and horror.”  (Beck, 2004a, p. 28).

Approximately 9% of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth. Most often, this illness is caused by a real or perceived trauma during delivery or postpartum. These traumas could include:

• Prolapsed cord
• Unplanned cesarean
• Use of vacuum extractor or forceps to deliver the baby
• Baby going to NICU
• Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery
• Women who have experienced previous trauma, such as rape or sexual abuse
• Women who have experienced a severe complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3^rd or 4^th degree tear), or cardiac disease

My therapy work with mothers is typically after a traumatic birth.  The more I learn about the mother’s labor and birth experience, the more I can understand what care and education could have better supported her during  birth.

The “3 E’s” – explain, encourage and empathize – can be a useful framework for obstetrical staff in lessening the risk of a traumatic birth.  

Explain  

When explaining a process, options or a procedure, always include the woman in the discussion of her own care.  There is a distinct difference in hearing a discussion and being a part of one.  If plans change, explain what is happening and what is needed to correct the situation.

Encourage

The connection a mother has with those caring for her during childbirth is deep — you are present during one of the most emotional, unpredictable times in her life.  Encouragement is empowering and can offer the mother a sense of control.  Encourage questions.   If plans change, discuss possible alternatives.   Using “we” in conversations shows alignment and rallying together.

Empathize 

Women in labor yearn for companionship, support and empathy.

Phrases such as “I know,”  “I’m here,” and “Yes” are phrases that connect staff with a woman’s experience when she feels pain, fear, disappointment or frustration.

I’ve heard many birth stories over the years; devastating stories of physical compromise, intense fear and loss of the baby’s life.  How the mother is cared for, is what she remembers.  The tone of your voice.  The gentleness.  The validation of feelings.  One of my clients was unaware she was being rushed for an emergency cesarean.  She said in all of the chaos and in a knee-chest position, she extended her arm and a nurse held her hand.  Beauty within terror.   It was a simple gesture and it has been the most powerful, healing memory for her.   Even in the midst of an emergency, someone saw her need.  Someone saw her.

Obstetric staff has great influence on how a mother remembers her birth experience.  Expressing empathy and explaining and encouraging a laboring and postpartum mom can influence her health and well-being.  New mothers who receive the “3 Es” can better transition to home, experience less anxiety, have more positive feelings about themselves and improved bonding with their babies.

Karin Beschen is a Licensed Mental Health Counselor specializing in reproductive and maternal mental health.  She also serves as a volunteer co-coordinator for Iowa for Postpartum Support International.

Additional Resources

Postpartum Support International 

PaTTCh (Prevention and Treatment of Traumatic Birth)

Improving Birth

References

Beck, C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research 53(1), 28-35.

Beck, C. T., Driscoll, J.W., & Watson, S. (2013). Traumatic Childbirth New York, NY: Routledge.

Working in neonatal intensive care can be tough no matter how long you have worked in it. With time however, many things become routine.  500 gram babies are our business.  Cooling asphyxiated babies is our business.  We are used to this world – the ventilators, the treatments, the pumps, the alarms.  The thing is, the parents and family are not used to this.  It is shocking, frightening.  It is our duty to remember this is their first experience in a world they never imagined, perhaps did not even know existed.  How can we as care providers support them?

Speak gently

Anytime I meet the parents of a NICU baby for the first time, I start by saying, “Congratulations.”  Whether the baby is a 23 weeker with a Grade IV bleed, a deeply asphyxiated baby, or an otherwise healthy baby in need of antibiotics, I acknowledge the baby.  This is now their world.

Speak Clearly

Parents want and deserve to be informed at all times.  They do not need a medical background to understand.  I speak simply.  If I am taking care of a baby that has just had a PDA Ligation, I tell the parents that we will be monitoring baby for pain, blood pressure stability, and infection.  I explain that we routinely give babies a morphine drip after surgery to treat their baby’s pain.  I also explain that sometimes baby can have blood pressure instability and may need support with medication.  In this way, they are informed of what is happening, can happen.

Speak Carefully 

I do not give false hope for a baby that is critically ill.  When a parent asks me if their baby is going to die, I respond by saying that the baby is critical and that we are doing everything we can to support them.  No one, not even the doctors, can predict with exactness what course the baby will take.  I never tell a parent that everything is going to be OK, even if their baby is stable.

Speak Calmly

Speak slowly, speak calmly.  Don’t rush when explaining something.  Take your time.  If they have questions that you can’t answer, tell them it is a good question for the doctor.  Take the time they need to help them process.  

Speak without Judgement

A new mom that is hysterical over the birth of her stable 30 week infant has the right to be hysterical.  Seeing a tiny premature infant in an incubator with multiple lines and leads is not the picture parents have when imagining their baby.  They imagine a robust baby in their arms.  Yes, they are lucky their baby is stable compared to the one with IVH, but this undermines what they are feeling.  We know that their baby will likely be OK, but they don’t.

They have every right to feel sad, frightened, angry.  It is the grieving process that they must go through.  When we assume the responsibility of the baby, we assume responsibility for the parents as well.  Our job is that of support – to put a hand on the shoulder, give a hug, get them a glass of water, answer their questions, let them know we are here.

Lori Boggan, RN
Lori is a NICU Staff Nurse at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California. Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works. She also write her own blog Neonurse at https://neonursetravels.com/

Premature babies depend on us as nurses and parents to be their advocates, their protectors, and most importantly their voices.  Their development in the NICU should mimic as closely as possible the uterine environment.  As new parents of NICU babies, it is often hard to understand this concept, and that is when the NICU nurse is your best resource for education about your new baby. 

As a NICU nurse for 8 years, and also a mother of 5 children, 2 being 34 week identical twins that spent time in the NICU, I have come to see both sides of the very challenging transition that is faced when you have a child in the NICU environment.  As parents all we want to do is snuggle with our new babies and offer them the comfort of our touch and our love, because we know that nothing calms a baby more than being swaddled and held by their mother or father. 

In the NICU that is not always possible, the way that the new parent wants it to be.  The NICU environment is often extremely busy, loud, and intimidating to new parents. Imagine what it feels like for the baby who has entered this world long before its brain, senses, and body have fully developed to handle all the stresses of a hectic environment.

As a NICU mom I knew the environment that I was headed into when my daughters were born because I was lucky enough to have delivered them in the hospital where I work.  They were admitted into my NICU surrounded by special friends, who were also my fellow co-workers.  My NICU is a single room NICU that offers each baby its own room filled with all the technical equipment to keep a baby safe, but also equipped with environmental advantages to help a baby adjust and thrive in a stressful environment.  Each room has shades on the windows to adjust natural light, dimmers on all the in-room lighting to adjust for a calming atmosphere, comfortable chairs where I could  relax when spending time with my babies, and temperature control specific to the room for  my comfort and that of my 4 pound newborns.

What stands out most to me during my stay in the NICU with my daughters was being able to come to the NICU and go to my daughter’s rooms, close the door, and spend quality time with my babies in an atmosphere that was close to a home environment.  I was able to pump breastmilk at my daughters’ bedsides while watching them in their isolettes, which is proven to help with milk production, all while in a very private, quiet, and comfortable environment.   These little environment pluses helped me and my babies more than you could ever know.  Being able to be skin to skin  with them in a private and comfortable place helped facilitate the bonding experience that is often not possible with NICU babies.  Each mother of a NICU baby deserves an experience like this to help facilitate the mother/baby bond that is so important to make as soon as physically and medically possible.

My NICU nursing experience has taught me so many important things about how to deal with my NICU patients and their parents.  I strive to offer the best NICU experience to both of them.  I spend a lot of time educating and explaining to new parents what their NICU baby is going to need from them and a time frame for when each new experience will happen.  This tends to lessen the anxiety that they are feeling and it also helps to make them feel like they are involved and have a say in what kind of care their new baby will receive.  My biggest goal when I have a new NICU family is to help them to initiate the bonding that they desire.  Skin to skin bonding is proven to both benefit the baby as well as the mother and father.  The first time a mother gets to bond with her baby, skin to skin, is a magical moment, not to be missed because of NICU environmental challenges.

Tracy Whitman, RN
Tracy Whitman is a Registered Neonatal Intensive Care (NICU) Charge Nurse at Moses Taylor Hospital in Scranton, PA. She has been a NICU nurse since 2007, graduating from Pennsylvania State University with her Associates degree in nursing. She continued on to get her Bachelors degree from Pennsylvania State University in 2010. She is currently enrolled at Drexel University pursuing her Pediatric Acute and Primary care Nurse Practitioner degree. She is a proud member of AWHONN where she is participating in the Emerging Leaders Program. She is also a member of the National Association of Neonatal Nurses (NANN), and the Sigma Theta Tau Nursing Honor Society. She was a finalist for NICU Nurse of the Year through the March of Dimes Association. She has recently obtained her Certified Legal Nurse Consultant certification, and is anticipating receiving her certification in Neonatal Intensive Care Nursing in mid-December. She resides in Scranton, PA with her husband and five children.

Photo @jocelyndale/Creative Commons

Having your new baby spend time in the Neonatal Intensive Care Unit (NICU) can be extremely stressful for both you and your baby. The bright lights, the random nature of nonhuman sounds such as beeps or monitors, and medical procedures can all create an uneasy or stressful environment.

This is concerning because stress can influence your baby’s brain development and how parents  interact with their babies. However, there are ways to help reduce the long-term effect of these stressors.

There are several things you can do as parents to help reduce NICU environmental stressors. Ask your nurse for help with these suggestions.

First is to reduce extra lightings and non- human sounds. Infants thrive on the mother and father’s voice.  Talking to your baby is easy to do.  Mothers and fathers instinctively raise the pitch of their voice and talk using a few words with a pause.

Another  way to help babies in the NICU  is to use a combination of procedures that can increase your understanding of and reactions to your infant’s behaviors; along with, providing your infant with positive sensory experiences. This procedure is known as Auditory, Tactile, Visual, and Vestibular Intervention (ATVV) also known as Massage Plus 30, 10, 5.

This practice helps to improve infant/parent relationships, increase infant alertness and pre-feeding behaviors, improve maternal confidence in caring for her premature infant,, and improve the baby’s ability to feed and grow.  Touch and human social interaction are important for an infant’s growth and development, and during the first few days or weeks of life babies are very sensitive to and receptive to these types of stimuli.

One mother delivered a baby born at less than 29 weeks gestation.  After she learned the ATVV and administered it for a few weeks, she stated “The ATVV made me more aware as a mother of what my child may like or dislike and to how recognize the difference.”

The ATVV procedures were developed over a 30 year period and include step by step instructions on how to introduce the sensory stimuli in a way that does not over stimulate the baby. The procedure begins with mom (or dad) talking to baby in a soothing calm voice (auditory stimulation). After 30 seconds of talking to the baby using a higher pitched voice and a few words with pauses, mom can then begin to massage the baby. Mom will massage each section of baby’s head, arms, legs, tummy and back, for 10 minutes. This is considered touch or tactile stimulation. Mom should continue to talk to baby and hold eye contact throughout the massage. Once the massage is finished mom should wrap baby up in a blanket and gently rock baby back and forth for 5 minutes (vestibular stimulation). Throughout this procedure mom should be watching for signs that baby is alert and enjoying themselves. A full instruction on how to do the ATVV protocol and tips to help understand your baby’s behavior can be found online.

Another mother had previously delivered more than three premature babies.  When she learned the ATVV for the first time on her baby who was born at 33 weeks gestation, she stated “I have never seen her so alert!”

Before starting any procedure like ATVV it is important to discuss the benefits and drawbacks with your healthcare professional, as each baby’s needs and situation is different. Work with hospital nurses, physicians, and other staff to help find ways to help reduce environmental stressors for your baby during their stay in the NICU.  They will be able to help facilitate your activities with your baby during visits such as the ATVV or skin-to-skin contact, reducing lighting and sound exposure,  and supporting non stress feedings.

No parent wants their new baby to be in the NICU in their first few days or weeks of life. However, for some with medical conditions and for those born too early, the NICU is the best place to be.  Finding ways to help reduce your baby’s stress when placed in the NICU  environment can have long lasting impacts on your baby’s development.

Rosemary C. White-Traut, PhD, RN, FAAN
Rosemary  is the director of Nursing Research at Children’s Hospital of Wisconsin. Prior to coming to the Children’s Hospital of Wisconsin, she served as professor and department head of Women, Children and Family Health Science at the University of Illinois at Chicago.