Tuesday, October 14, 2014

Doula DO's and DONT'S for families considering Doula Care, IMHO

I'm going to do my best to tackle an enormous topic here.  Almost two decades ago, when I started attending births in this area...the beautiful Pacific Northwest...this profession was almost unheard of.  Even 5 years ago, when asked at parties what I do for work, and I answered "Doula", I was mostly met with blank stares.  We now have a very different culture here, and now when I state my profession at dinner parties, it is common for me to hear "Do you know________? She was my doula/she's a friend or relative...
This profession has become necessary for a couple of important reasons, in my opinion.  First and foremost, we don't often live in the same area as our immediate or extended families.  Once upon a time, not too long ago, women were surrounded by immediate and extended family and the women in a family or community would provide this service much of the time.  Mother's, Aunts, Grandmother's, even daughters or niece's may have been a part of a laboring woman's circle.  Midwives moving into the modern era and being licensed has significantly increased the numbers of practicing midwives, both in and out of hospital, which is wonderful. Along with this privilege to practice, came the need for rigorous documentation which requires more of their time spent charting if compared to the constantly attentive homebirth days of midwifery care. A small price to pay to have the option. Additionally, in hospital, the role of the nurse has significantly changed in scope.  Hospital budget cuts and misappropriated funding have altered the nurse to patient ratio, lawsuits have increased the need for constant documentation and data entry, policy has created monotonous and incessant repeated questioning of the patient, doctors delegate more and more clinical tasks, often leaving the true definition of "nurse" in the dust.  Synonyms listed on Merriam Webster:


administer (to)care (for)minister (to)motherdo for [chiefly British], look afterlook out forlook tosee totake care ofwait on (also wait upon)

Before anyone freaks out, I want to go on record saying that there are ABSOLUTELY many many many dedicated, warm, attentive, caring, nurses out there that go above and beyond the call of duty and fulfill both their clinical responsibilities as well as truly serving their patients in the spirit of the above definition. We have though, lost the ability to count on it, and so the professional Doula emerged and continues to grow.  

This new culture has some challenges, since there is no real way to regulate ALL people who may be in attendance as a support person at a birth.  I had my Mom and my husband there supporting and guiding me.  They had read some books, knew me, knew what I believed, and knew what I was hoping for.  That is the extent of their accreditation. Anyone can call themselves a doula if they are supporting a laboring woman, in fact, I guess even my two year old daughter who was present at her brother's birth and had the very important job of wiping my forehead with a cool cloth, was my doula.  There are also licensed Midwives, nurses and other professional health care providers who serve in this role, and readily apply skills and knowledge that FAR surpasses the traditional role of physical and emotional, nurturing, care, comfort, and support of doula care.  And there are doula's who fill out the spectrum in between.  So how is one to determine what a reasonable "scope of practice" for a doula is?  Let's start with the term "scope of practice".  That term already irks me, "practice" is a term that feels very medical and formal to me and I don't use it in my work.  I'm not a "Practicing Doula".  I am a Doula. Some of the children I have witnessed coming into this world call me "Doula", as if it's my name. I am reminded of how the term "nursing" went from the above definition to the far more medicalized presence that we see in our hospitals today.  Using the term "scope of practice" seems like a gateway to being controlled by the medical community, which is in absolute opposition to what I believe my role to be.  A doula is NOT medical, and should not be using terminology to try to sound remotely medical. Again, my opinion.

Certification.  There are absolutely some amazing "certified doula's" out there.  However, I am not of the opinion that you have to have a certification to be amazing at this art.  There are organizations all over the place trying to make money by offering certifications for a million professions that require no formal education; only passion, knowledge, experience and of course, skill.  Certs can range from a very inexpensive, very quick, online class to a prolonged course costing thousands.  Having a certification does not prove or disprove a doula's inherent skill.  Almost anyone can take and pass the classes.  Many certifying bodies are just out there to make a buck. The class may be fine, the knowledge may be useful, but most of us are perfectly capable of reading the books, watching the video's online, and learning how to go about running a small business/sole proprietorship without a class.  The challenge is sifting through a lot of data and video's to get the right ones that will earnestly prepare you to attend a woman in labor.  In my area,  SO MANY doula's never end up working in the field because there are just too many trying to gain invitation to births to complete their certification process, or just to gain experience, and if they are blessed enough to get into a birth, they are often working for next to nothing until they have enough experience to really have some expertise to offer.  That's alright, those who are the most passionate, the most knowledgeable, the most skilled will usually rise, and get the grass roots referrals from care providers and clients alike. Being relatively anti-establishment, as well and honoring the true, historical, familial, attendant, mothering, care taking, nature of being a Doula, I see no need to be certified.  In fact, I think that creating a certifying body, especially as a "for profit" business, de-values the ancient art. I continue to read and learn, I continue to attend births in my area and therefore have my finger on the pulse of the birth culture, in and out of hospital, I respect the women I work for  and work to meet the individual physical and emotional needs of my client...not "patient"...to the very best of my ability.  I don't mean to say that becoming certified is bad or wrong,  I was technically "certified" for a decade.  It is certainly an introduction to the art, and your school may provide ongoing continuing education which will help you stay current with the birth culture, just know that the role of the doula is not rocket science, it is achingly and beautifully simple in many ways.  The perfect system is likely a combination of either a certification OR independent study, coupled with an apprenticeship.  Attending births with a mentor is probably the easiest way for a doula trying to build her experience to gain invitation to births and to have someone to discuss the labor and birth after the fact, wringing every ounce of knowledge out f the experience. I love having apprentice doula's working with me, with my clients permission of course.

The Role of the Doula
Again, this is my opinion...I'm not suggesting that I know everything, or that this definition is true for all doula's or all clients. The following is simply an ever evolving list of hats that I have worn at births during my career.  It is also a list that my clients understand prior to hiring me, often prior to interviewing me, for doula services.  While all doula/client relationships and all doula style's and interpretations may vary, I believe in the free market in this instance and trust my clients to decide if I am the right fit for their family and their desired birth.

  • Being a presence with experience.
  • Timing contractions, documenting fetal movement.
  • Evaluating the progress of labor using external signs and symptoms.
  • Facilitating labor progress: using positions/avoiding positions/encouraging movement/encouraging rest/using visualization/maintaining hydration and energy/acknowledging and resolving fears by translating her physical sensations and discomforts into the logic of labor progression.
  • Creating the desired environment and minimizing discomfort using: conversation or lack thereof, music, candles, deep abdominal breathing, showers or baths when appropriate, aroma therapy, room temperature, keeping the area tidy, keeping certain people present, keeping certain people away, using massage, maternal touch and warm or cold compresses.
  • Provide information to help clients to move to their intended birth location or request the Midwife to join us.
  • Take pictures or video, or both.
  • Assist the woman in making the transition to the pushing stage of labor, coaching her through until she recognizes the rhythm. 
  • Physically supporting women in positions when necessary to minimize the strain of holding herself in a squat, for example.
  • Informing clients if I see "red flags" indicating a questionable routine intervention.
  • Educating clients about alternatives to routine interventions when possible.
  • Educating clients about any un-disclosed risks of intervention(s) and the procedures that accompany most routine interventions.
  • Advocating for clients who have expressed specific wishes, no matter how few or how many, regarding their care and the care of the new baby.
  • Partnering with primary coaches so that he or she (or even they) can be in the role that the family wishes for them to be in, in the place where the laboring woman needs them to be.  Knowing in advance what everyone desires from the experience allows me to facilitate those wishes and do my best to make your experience as perfect as I can under any circumstances.
  • Helping women/couples understand when a deviation from their desired birth experience is necessary and being informed so that they leave the experience knowing that every question was asked (when possible) and every alternative was discussed and/or implemented (when safe).  My goal is that my clients know that no matter the outcome, they made responsible choices for the safety and well being of mom and baby.
  • Supporting women immediately postpartum by helping with breastfeeding, continuing advocacy for newborn procedures, and taking care of peripheral responsibilities (ordering food, cleaning up,  pushing fluids when depleted during labor, photography/videography, bringing in family members, etc) so the family can focus on falling in love.

So, not all women will need all of these things, and some women will need things that I couldn't imagine in a million years. We learn over time not to judge...but to be discerning. If there is ANYTHING that comes up that I feel falls into the category of "medical", there will be a communication between my client and her medical team.  This means reporting a broken bag of fluid, any amount of blood that meets or exceeds their directive to make contact, changes in consciousness, anything that the care provider has asked specifically to be notified about, etc. I am not medical professional, and take a great deal of pride in that, actually, but I will pay attention to the requests of their care provider and additionally, will likely notice if anything is happening that I understand the doc or midwife would want to know about.  This is not my responsibility, but I'm happy to be a second, and slightly more experienced pair of eyes and ears.

There is a new breed of doula out there that significantly blurs the line between doula and medical care provider and I want to go on record saying that if a doula is offering any degree of clinical evaluation...know that she is not acting as your doula. Most of the time I consider it part of my job to assist in helping women to avoid nonessential intervention, so why on earth would I be offering it myself?  Some examples of things I consider medical are:

  • Anything involving the physical well being of the baby or mother, above and beyond what a couple would be asked to monitor independently.  For example, families are often asked to track fetal movement, so even though I don't use the data to diagnose or treat anything, I will jot it down if mom mentions baby kicking to help the family communicate with the care team accurately.  I feel comfortable assisting in timing contractions because families would be asked to do that with or without me.  I don't evaluate fetal position, I don't offer sterile water injections, I don't listen to fetal heart tones, I don't check maternal vitals, I don't use a Rebozo for fetal positioning...this is an odd cross over, I think. Why would a doula make any attempt to manipulate or reposition the baby? I don't know what position the baby is in and it is not my role to assess.  Definitely medical, even though the rebozo looks like a little swath of fabric, a scarf, really, its use for anything other than comfort (hip squeeze, gentle hip support, etc.) by a doula is reckless endangerment in my opinion. To be manipulating the belly IN ANY WAY is irresponsible.  If the medical team wants it done, they should do it themselves.
  • Vaginal exams...Seriously!  There are Doula's out there, usually falling into the category of either a "Montrice" (A birthy person trained to perform some clinical tasks), or a midwifery student or midwife who also moonlights as a doula.  One of my main objectives is to help my clients limit cervical exams as much as possible, not performing them myself.  One component of the art of being a doula is to learn to ascertain (using external signs: words, behaviors, discomfort, positions, needs, appearance) the approximate stage of labor and provide appropriate care and comfort based on the needs of the laboring woman in that stage.  I'm a big believer in the sphincter law that Ina May Gaskin talks about in her book "Ina May's Guide to Childbirth" and I am also very aware of the fact that if I had done an exam on a woman and determined that it was time to go to the birth place, my examination will NEVER prevent another exam from being done upon arriving at the birth center or hospital, they will want to assess her cervix themselves and therefore I would just be yet another person violating her sphincter, causing her stress, and potentially introducing bacteria.  No thank you.  
  • Giving her (even if requested) herbs, supplements, pills, or tinctures without consulting with her as well as her care provider first.  This does not mean that I won't hand her or bring her any medicinals that she researched, discussed with her care team, and brought for herself.  If her mother was there, or her grandmother, they would meet that need, and so then will I. 

I hope this article will be helpful, to families who are considering hiring a doula, as well as lending my 2 cents to the discussion of what the role of the doula includes and what it doesn't.  If you are in need of some education prior to interviewing doula's and you are unable to attend my classes (I'd rather deliver the information in person!), please consider purchasing my textbook/workbook.  It is a concise 192 page workbook that will educate you about preparation for birth, provide a thorough account of the labor and birth process, it will assist you in the creation of a your birth plan because the truth is, that barring overstepping my boundaries into medicine, or not meeting the parameters of the contract we have agreed upon, my job description is the birth plan as written.  It will additionally inform you about common practices in and out of the hospital, offer a variety of relaxation and support techniques for you to try out, which will be a big asset to anyone serving in the "doula" role, whether it's your husband/ boyfriend/spouse/partner, you mom, a friend or relative, or a professional doula.  Knowing what comforts you and providing it at the right moment is an elemental part of this caring profession.

Here is a link to find it on Amazon: 
Expecting Kindness by Kristin Dibeh

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