About Doulas Behaving Badly

I was thrilled to see this resurface from Mother Wit Doula Lesley Everest. I, too, have been told by nursing and OB staff that I'm one of the only doulas they like -- those "other ones" have hidden agendas, or think their wishes are more important than the mother's, or are argumentative. 

In my professional support network, I don't have colleagues who see their role as agitator. And most of us have a preference for what  the mother in the room is showing us, so much so that we don't use information from the fetal monitor, let alone tinker with the machinery.  Do those doulas really exist? Who knows?  Everywhere, but particularly at the larger hospitals where I work and may not be a familiar face to the enormous staff, I mind my place within the hierarchy of hospital culture, and exercise my greatest skills in grace and diplomacy while still meeting the emotional and physical needs of my client. In the eyes of hospital staff, I am only as good as the doula they met before me, whether she is real or a stereotype, and so I am careful. Not only do I love my job, I also care deeply about my profession and the visibility of my professional community, and I envision a day when doulas are a valued, readily accepted part of maternity care

But sometimes it is tricky. As a doula, I have the benefit of a prenatal relationship with my clients, whereas the nurses and OB/midwives don't. There's a lot that I know about what sorts of meanings a woman has associated with her pregnancy, labor, birth, and post-partum. A few weeks ago, my client gave birth to her beautiful baby girl. My client had had a breast reduction some 15 years prior, and it was a goal for her to have as much of a breastfeeding relationship with her baby as she possibly could. She'd done so much reading about Breastfeeding After Reduction, perhaps even more than she'd read about birth.

She knew about the benefits of immediate, uninterrupted skin-to-skin, and it's correlation with higher breastfeeding rates. She reviewed it with her OB, who assured her that skin-to-skin was preferable also from the hospital's point of view, and that as long as there was no need for the baby to go to a warmer or be evaluated by pediatricians, skin-to-skin was the plan. And it did happen. Immediately after the baby emerged, she was placed right on her mother's naked, warm, receptive chest.

For seven minutes.

At seven minutes of life, definitely not an hour, and certainly not before the OB was done even repairing the perineum, the nurse said "Let's weigh her. Of course you want to know what the baby weighs, right?"

A doula's best advocacy tool is to remind her client about choices. If it isn't feasible for the mother to absorb that in any moment, then the next best person is her partner. My client's partner, her husband, was within my reach at that moment. I tapped him on the back and whispered in his ear -- "Do you want to know what the baby weighs, or do you think they'd like more skin-to-skin time?"  He moved quickly from behind his camera and asked the nurse, very politely, for more time, since mom and baby seemed so cozy,  and the nurse agreed.

At 20 minutes of life, so 13 minutes later, the nurse indicated that she needed to weigh the baby  in case she was over 9 lbs and needed blood sugars tested. Baby weighed in at 8.13, and the nurse began to diaper the baby, cover her sweet head with a hat, and then laid out swaddling blankets.

This time the dad was out of my reach, so I couldn't whisper a reminder of all that the mother had read and wanted. It is usually my last option, but I had to exercise it -- and I asked my client in my normal voice, "You can hold her again. Do you want her swaddled, or do you want her naked on your skin?"

The mother's eyes lit up with excitement. "Oh, naked for sure!"

The nurse's jaw stiffenened tight as she began to undo the swaddle. She was definitely displeased and looked at me sternly as she said, "Just be sure the baby is warm enough."

So is that the equivalent of taking a patient off a monitor? Is that the same as undoing an IV? Am I a doula behaving badly? That nurse probably thinks so, and I don't think I've done much to advance my field in her eyes.

But I can live with that.

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--An Unmedicated VBAC? Really? --Yes, Really!

My client was underneath a heated blanket, her naked newborn boy snuggled on her naked chest. She was marvelling at how special the immediate skin-to-skin experience was, particularly because she had delayed skin-to-skin with her first, as she was born by c-section. This was one of her largest motivators in aiming for a VBAC.

"That was amazing," she said. "I can't believe I did it."

"Not only did you do it," chimed in the attending OB from where she was counting instruments, "but you did it unmedicated. Almost no one can say that."

My client's VBAC certainly is a personal victory; given today's VBAC climate -- despite the NIH findings that a trial of labor after a c-section is actually safer than a repeat c-section -- it is a political victory as well. But the OB's comments are sticking with me because my witnessing of unmedicated VBAC seems to be the direct opposite of hers. I have attended about a dozen VBAC's in the past year, and all but 2 did it unmedicated (and those two had c-sections, one after a trial of labor, the other with no trial of labor).

Looking at older (2005) statistics from the MA Department of Public Health, epidural use was between 60-70 percent at the hospitals I frequent the most. Whereas those who work on L&D have seen probably thousands more births than I ever will, I think I have been a part of more unmedicated births because I am trained and experienced in specific, non-pharmacological, emotional and physical comfort measures that provide pain relief, and because I provide home support -- where that is the only option available.

My client had been admitted at 8cm, and was showing some of the "classic" signs of transition. All kinds of things were coming out of her mouth. Her sentences, all stream-of-consciousness and irrational, generously peppered with various forms of the word "f*ck," were basically amounting to the fact that she didn't want another single contraction, and that she wanted to put on her clothes and go home. When she said she couldn't figure out if she needed to pee really badly or if she needed to have a bowel movement, she began asking for an epidural.

When the OB said she was dilated to "9 and a lip" (a lip is a bit of remaining cervix that has not dilated), all my client heard was that she wasn't 10 cm, and her request for an epidural turned into a demand. Feeling the arc of this birth unfolding, I did exactly as I had promised her I'd do if she asked for an epidural -- talk her out of it. I explained to her that all the pressure she was feeling was the baby moving down through her pelvis. She resisted, saying again that either she wanted to put her clothes on and go home, or get an epidural. The nurse said, "OK, if you're sure an epidural is what you really want." She said it with great hesitation, probably because she knew this baby's birth was not far off, and because by the time anesthesia would have gotten there and placed the medication, the baby would have been born already. And probably because she didn't know what else to say, other than the words she needed to order an epidural .

Knowing that pushing would be a relief, as it is for many women, I said to her, "Pushing and getting this baby out is the best pain relief you can get." I asked the OB quickly, "Can she push past the lip?"

The OB took a deep breath and carefully considered my question, and I wondered if she'd ever been asked that before. I could practically see the light bulb going off in her head before she said, "I don't think that pushing past the lip will interfere with her progress at all."

My client needed convincing to push, so I suggested she push just to try it, and see if it helped any. The lip was anterior (towards my client's pubic bone), so I suggested she get back on hands and knees so that the baby's head would finally press out that lip. She pushed with the strength of an army of men, and 20 minutes later, my client was holding her baby in her arms.

What would have happened if my client had gotten the epidural, assuming that there would have been time to place it? Her baby was coming with such force that it is doubtful an epidural would have slowed the contractions, especially at 9+cm. For the same reason, I can't imagine it would have drawn out the pushing stage into anything long and exhausting, as can also happen with an epidural. She would have had a happy and healthy baby, and she would have done so via VBAC. And retrospectively, perhaps she would have been just fine with getting the epidural, especially when she'd get to the part of the story where she would describe the amount of pain she was in. It all would have been fine, probably, but I am thrilled that my client does not need to reconcile her goals for her birth with its outcome.

Lesley Everett, a doula in Montreal, just led a doula training for L&D nurses. The snippets of what she shared from that experience are encouraging -- many of the nurses who attended expressed some layered frustrations; not only do they not have the knowledge on how to support women who are laboring without an epidural, they have too many patients at one time to provide the focused and concentrated work of unmedicated labor support. Combine that with the fact that the spectrum of emotions and behaviors that unmedicated women present with can be pretty darn intimidating if you are not accustomed to it. What results is a lack of practice, which leads to lack of confidence, which leads to a lack of practice.

I am heartened by Lesley's work, and I'm hoping that my client's birth experience prompted some out-of-the-box thinking for the hospital staff involved, a gentle reminder that babies are born in hundreds of ways, as long as the mothers have knowledgeable support.





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