Dear Readers: I would like to thank all of you for the many (oh so many!) questions you have submitted around the topic of singing, pregnancy, and young motherhood. Although we had promised to respond to each individually, I have decided instead to write a single, longer piece which will hopefully answer most of your questions. I did this for three reasons: first, many of the questions were similar and can be covered together. Second, some of the questions were very specific for one individual and of limited interest to most of your fellow singers. And, finally, I don’t know the answer to some questions! So, rather than give a misleading answer, I remain (happily) an otolaryngologist and feel it would be better for you to talk to your gynecologist or fertility specialist about these concerns.
First, let me make a few general comments about infertility issues. If you are given hormones, either to induce ovulation or to facilitate implantation, these will have an effect on your voice. Most hormones, except for androgens, should cause only a temporary change in the voice, but the change may be persistent if you are making repeated or prolonged attempts at fertilization. Estrogen and progestins cause fluid retention, although synthetic progestins may break down into androgen-like compounds which can darken the voice. Lighter and higher voices are more at risk here. I can’t comment on specific medications or specific cases, and you really need to explore all of this with your fertility specialist, and then weigh the risks and benefits.
But let’s assume you have become pregnant, perhaps the old-fashioned way. Pregnancy is a time of profound physical and emotional change, which is driven by hormones and which affects every part of your body. Furthermore, as pregnancy progresses, these changes become more marked. Although delivery normally represents the end of pregnancy, the hormonal environment remains altered and doesn’t return to normal until you have finished lactating and your periods have commenced again. So for singers who plan to breastfeed, these alterations may potentially last one to two years. Our bodies carry a remarkable variety of “as needed” information, reflexes, and capabilities which only manifest under very specific circumstances, perhaps only once or twice in a lifetime. Childbearing is a prime example of this: consider the letdown reflex—a new mother may start lactating spontaneously, triggered by nothing more than the sound of a baby’s cry.
From a greater perspective, singing during pregnancy is probably not as important for the survival of the species as making another human being. Nonetheless, many professional and amateur singers need to (or choose to) continue to sing during this time of great physical change. And, in general, there is no reason why you shouldn’t—as long as you accept the limitations imposed on your vocal mechanism and lungs, your physical and emotional endurance, and what’s going on below your diaphragm.
Let me preface everything that follows with one important disclaimer. Every woman is different! For many reasons, some can sing seemingly effortlessly (or with only mildly modified effort) through their entire pregnancy, stop right before delivery, and return to singing a few weeks later. Others are significantly vocally disabled for much of their pregnancy—and after delivery and weaning, they get back to singing with great effort, only to find that their voice and their technique have changed.
Looking at the hormones first, when you become pregnant, the normal cycling of estrogen and progesterone stops. Progesterone, or progestins, dominate the scene now. As the name implies, progestin promotes gestation: this allows the ovum to implant on the receptive surface of the uterine wall and for that attachment to continue as the baby grows. You will recall that progesterone is the dominant hormone during the week before your period, often a time of salt craving and fluid retention. This effect also occurs during pregnancy—there is a tendency to retain salt and for your tissues to swell. From the vocal point of view, hormonally driven fluid retention carries the same problems as singing during the premenstrual period—the voice may lose some sonority, and the high notes, especially with soft singing, may be unwieldy.
This is why pregnant women are encouraged to avoid salty foods, since the combination can lead to hypertension during pregnancy. Women who are prone to high blood pressure may develop a severe and dangerous form of hypertension during pregnancy, called preeclampsia or eclampsia.
The second hormonal issue pertains to low estrogen. Not only does progesterone dominate during pregnancy, but following delivery, prolactin bThis hormone, as the name again suggests, supports lactation. But prolactin also suppresses estrogen and, in fact, suppresses normal menstruation. This built-in birth control is great, since it prevents the mother from becoming pregnant until she has stopped breastfeeding. On the other hand, the suppression of estrogen has a negative effect on the voice, almost like a temporary mini-menopause! So singing during breastfeeding may be unreliable. Not until the child is weaned, prolactin levels drop, and the normal estrogen/progesterone cycle resumes will the voice return to its normal state.
For the sake of our discussion, the entire period can be divided into six parts: the three trimesters, the delivery, the postpartum period, and the period of lactation (which ends with the return of the menses).
The First Trimester
Each trimester of pregnancy carries its own signature as far as singing is concerned. During the first three months, you should have no significant difficulties, apart from morning sickness and the possible irritation to the throat that may come from vomiting. The effect of gastric contents coming up into the throat can cause irritation of the pharynx and elevation of the larynx. There are of course also hormonal changes, as discussed above, and you may need to more actively support the voice, especially at the top of your range. During the first trimester, the uterus is still below the pelvic rim and should not encumber your breathing or diaphragmatic movement.
The Second Trimester
In the second trimester, an expectant mother typically feels well, but the increasing distention of the abdomen can make support more difficult toward the end of the trimester. At the end of the sixth month, the top of the uterus is at the level of the navel, compressing the contents of the abdomen and resetting the “resting position” of the abdominal muscles. Interestingly, the mild stretch of these muscles can initially make contraction and support easier. All of these phenomena vary, depending on whether the expectant mom is slim or overweight, and also varies with the size and shape of the pelvis. How you “carry” the baby (high or low) are also factors, since carrying high will more quickly press up on the abdominal organs and the diaphragm.
Support is also compromised by the necessary adjustments in posture, as your center of balance shifts forward. The normal inward curve of the lumbar vertebrae (lumbar lordosis) is accentuated as the gravid uterus pulls the abdomen forward and downward. Support becomes more of a problem as the baby grows. The issue is not so much support in the conventional sense (although the muscles of the abdomen are stretched, they still work and are able to contract), but you will be unable to fill your lungs as fully, since descent of the diaphragm is impaired by the rising uterus. Long phrases become difficult—you may need to revise your breathing for certain types of music. Lower back pain is common, and contraction of the postural muscles of the back (like the psoas major) may sympathetically increase the muscle tone in your other muscles, such as in the pelvis.
There is another potential issue with the lower back that the late second and third trimester mother should consider. One of the “as needed” contingencies in the pregnant woman is the synthesis of a hormone that loosens the ligaments and tendons. Appropriately named relaxin, this hormone can increase the possibility of dislocations and certainly worsen problems in the lower back. If you need to sing on stage, the angle of the stage’s rake can become an important factor in your ability to perform, since your center of gravity has shifted, the curvature of the lower back is exaggerated, and the protective tendons and ligaments are looser than normal. Incidentally, relaxin is an amazing hormone: in rabbits, which give birth to multiple babies, relaxin actually dissolves the fibrous connection between the two pubic bones in front, allowing the rabbit pelvis to open like a book during delivery!
The Third Trimester
In the third trimester, all of the phenomena listed above become more encumbering. Around the seventh month, the top of the uterus is typically at the lower tip of the breastbone (xiphoid process). This is the highest point during pregnancy: in the eighth and ninth months, the uterus comes back down and protrudes forward. This is when the woman looks really pregnant and needs to rebalance her gait and standing posture. Fortunately, breathing becomes easier as the uterus moves away from the diaphragm.
GERD (gastroesophageal reflux disease) is a frequent accompanying feature of pregnancy, and becomes an increasing problem as the enlarging uterus presses up on the stomach. Not only are the contents of the stomach (acid and enzymes) pushed up into the esophagus, but parts of the stomach itself may be pushed into the chest. The hiatus—a slit in the diaphragm through which the esophagus passes down to the stomach—may be stretched, allowing the lower esophagus and stomach, which normally belong in the abdomen, to slip up into the thorax, a condition known as a “hiatal hernia.” If a singer develops this condition, it may or may not reverse completely after delivery, or it may recur if she puts on weight over time.
The effects of GERD on the voice are well known. Management of this problem includes measures such as elevating the head of the bed at night, using liquid antacids at bedtime, and generally controlling weight gain during pregnancy.
If your pregnancy was the successful outcome of in vitro fertilization, you may give birth to more than one baby, since several ova are typically implanted. This means, of course, that all of the comments regarding weight gain, reflux, postural changes, and breathing problems apply, but even more so!
One feature specific to the third trimester is increasing physical fatigue, which continues well into the postpartum period. Women need more rest. The quality of sleep changes—they may need to sleep in unaccustomed positions to accommodate the baby. Synthesizing a new human is hard work for your body, and you need to adjust your singing and performing to accommodate. Even if you have sung well during the first two trimesters, expect less endurance as you round the home stretch. As you change your technique, support, breathing, and laryngeal posturing to accommodate your (temporarily) new body, do this with conscious awareness, since you will have to unlearn this compensation after the baby is born.
Delivery
Delivery is a messy but magnificent event—one might say the raison d’être for our sexual existence. From the laryngeal point of view, it can be highly traumatic. Pushing for many hours can cause at least vocal fold edema and, in some cases, vocal fold hemorrhage. Holding your breath and pushing raises the blood pressure in your head and can even cause some small blood vessels to rupture: it is not uncommon for women to develop facial edema or pinpoint bleeding (petechiae) in the skin of the face or over the sclera of the eyes.
A similar phenomenon happens to the vocal folds, which are contracted and forced together repeatedly and for prolonged periods during delivery. Vomiting is not uncommon. Much more rarely, stomach contents are aspirated into the larynx and trachea—a condition which carries the bizarrely musical name of Mendelssohn’s Syndrome.
If delivery is by C-section, this is a decision that may be made emergently and after hours of attempts at pushing the baby out. Even if it is a planned C-section, the woman is usually intubated, so some intubation trauma to the larynx may occur.
For all of the reasons above, you should not consider singing for at least two weeks after delivery. While beneficial to the vocal folds, two weeks of such voice rest also allows the larynx to rise up in the neck into a position that is too high for optimal singing. So don’t be surprised if your voice is below par. It will recover, once vocal fold edema or possible hemorrhage has resolved and your larynx is down where it should be.
Postpartum
In the postpartum period, two new issues are at play: vocal support and depression. Over the previous nine months, the abdominal muscles have gradually stretched out to accommodate the baby, and now they are loose. They have nothing to push against when you try to sing. The effect is similar (but even more dramatic) to what you might see with sudden severe weight loss. If you had a C-section, the abdominal muscles (recti abdominis) may have been further traumatized.
The muscles of the pelvic floor are also stretched and loose. If you had an episiotomy, pain in the perineal area is another burden. Over the ensuing few weeks, the abdominal and pelvic muscles will gradually tighten, but they may not go back to singing “trim” for several months. Kegel exercises are helpful to tone the pelvic floor muscles. You can also gently work the abdominal muscles, with advice from your obstetrician, but expect this to be a slow and gradual process.
Postpartum depression is common, and may range from mild to severe. Expect to feel at least a bit down, since this also has an effect on your singing.
Breastfeeding Period
The prolactin issue has already been mentioned earlier. If you plan to breastfeed, expect a period of relative estrogen depletion, which can change your voice—less resonance, less color, less pliability to the vocal folds. This may continue into the sixth part of our discussion, when abdominal and pelvic tone have recovered, laryngeal edema from pushing and reflux has subsided, and laryngeal position is back to its vocally appropriate position—but the voice is still not right! Don’t be impatient. Modify your singing schedule and repertoire to accommodate your temporary impairment. Things may not get back to normal until you have weaned the baby and your periods have resumed again.
Expect also to be chronically tired—your schedule now must mirror the baby’s. This is the time that once was called the “period of confinement.” You can certainly vocalize a bit, but spend your time sleeping as much as you can between feedings.
While from the singing point of view, choosing not to breastfeed may speed your vocal recovery, the physical and emotional advantages of breastfeeding to both you and the baby are so overwhelming that I would never advise this to any new mother, singer or not.
Summary
By way of general advice, I would suggest the following. Expect changes in your voice, your support, and your endurance, and accept these as part of the normal physiologic changes associated with pregnancy. Sing within your comfort zone. Each woman experiences pregnancy-associated vocal changes differently, depending on hormones, how much weight you gain, and how you carry the baby.
Singing can be continued as long as you are comfortable, depending on your Fach, the role, your general physical condition, and the effect of pregnancy-related hormones on your voice. Stage performance, however, must take into account the increasing limits on your general endurance as your pregnancy continues. And consider the physical limitations of stance and posture. You are certainly less poised and “athletic” when pregnant.
Above all, don’t be too hard on yourself and your vocal instrument—you are very busy making another human being! Pregnancy and childbearing are an incredible and unique adventure. This is a full-time job, but one that lasts only a few months. And you have the rest of your life to sing, perhaps beginning with a lullaby to your new baby.
