Saturday, March 6, 2010

A Path to Good Doula/Midwife/Medical Professional Relationships

On the heels of my last blog "Doulas Behaving Badly", having acknowledged that we doulas understand why midwives and medical practitioners (OB/GYNs, family doctors, and nurses) are often wary of embracing us as valuable members of the birth support team, I would like to now put forth a few points to help you understand doulas a little better in the hope of bettering our relationship.

My intent as a primarily hospital birth doula is to help a woman understand her birthing options in the hospital given the policies of the hospital she chooses, encourage free flowing patient/medical professional communication, help the couple clarify their values surrounding their childbirth experience, empower the couple to make decisions based both upon those values and their needs as discussed with their midwife/medical practitioner, then support those choices. My prenatal appointments are geared towards taking a thorough history of each woman, figuring out what the couple fears about birth, filling in some of the gaps they may have in understanding the birth process, gauging her emotional state, getting a sense of her relationship to stress and pain, knowing what resources (both internal and external) she has access to as well as guiding her towards using and expanding (if necessary) those resources. Our extensive prenatal work is geared towards building confidence in her ability to give birth normally, as well as helping her partner feel good about his/her role in supporting her with the challenges of labour and parenting.

During birth, my job is help the woman and her partner ride the waves; the waves of contractions, the waves of hospital shift changes, the waves of questions and explanations, and the waves of emotion. I am their anchor. The unique rapport I have built with my clients helps them to navigate these waves of the unknown with the comfort of an experienced "surfer" as a guide. My presence helps the couple from being swallowed up and swept away, which is a very easy thing to happen systematically in a big hospital full of people who are comparative strangers. Please understand this is not a personal criticism of any medical/midwifery practitioner. In fact, most of the practitioners I work with acknowledge this impersonal care to be one of the challenges of hospital birth. This does not mean it is a place that lacks compassion and kindness. Not in the least. It just means that the way the duties are set up for hospital staff members, the intensive attention a couple needs to good physical comfort and emotional support is not readily available.

I have had nurses be brutally honest with me, which I appreciate. Some have explained, "It's not that most of us are opposed to natural birth (though some are...they are taught about the dangers of birth and the superior value of medicine, so it makes sense some of them are mistrustful of that natural process), it's that with all the work we have to do we just find it easier to have a woman on an IV, monitor, and epidural. If something goes wrong, we're prepared. Also, because we have to divide our attention among several patients, we are relieved to know they're not suffering with their pain." I totally understand this given where they`re coming from as well as their crazy level of responsibility. But to the average client looking for an enriching birth experience in a hospital, this scenario the nurses describe is their very definition of being frighteningly "swept away". So, if a doula can be trusted to provide that focused attention to non-clinical needs and let the nurses, doctors, and midwives do what they need to do to be the life preservers in this "surfing" scenario, we could have a really nice thing going on, giving birthing couples safe AND fulfilling care.

So, there are a few things I would like the general population of midwifery/medical professionals to know about my practice, perhaps dispelling a few myths and shedding light on some things you may not know about doulas (obviously I can't speak for all of us, but many would concur). The best way to do this is by exploring some of the assumptions I commonly see made about me and my work, which is probably reflective of what most doulas experience. Perhaps I can put some things into perspective.

1) Doulas are the ones who make birth plans for their clients.

The more experienced a doula is, the less I find she supports this whole birth plan writing phenomenon. Sure, we encourage clients to go over them to clarify their values by outlining options and hospital protocols, but we don`t normally have them bring a paper to the hospital. I don`t, anyway. I believe the term "birth plan" is pretty close to oxymoronic. If a woman is gung ho to write one out in detail despite my gentle explanations of how these take up staff time, which can sometimes make them a little on edge, it`s their business and I`ll support them. Staff members sometimes interpret a birth plan to mean the woman believes she will most certainly be the victim of all kinds of terrible things "done" to her if she doesn't write down all the specific things she will or will not tolerate, as well as demonstrate a belief that one actually has much control over a process one can never predict. I know this is not the intent of most women, and that they are very heartfelt and reasonable wishes. But the truth is, the vast majority of birth plans look exactly the same. Most people have the same statement, ``If my baby and I are fine, I would please like to avoid any unnecessary interventions, and I`d like to be able to move around as much as possible, etc. etc.`` They get very repetitive for everyone after a while, I realize. So PLEASE don't blame the doula for a long birth plan that ends up being a pain your butt. Essentially, if she does have a birth plan, I assure you it is not us pulling the strings and making her state these choices to play out our agendas...it is her own form of empowerment and it is her right to do so. There are HER choices, not ours.

2) Doulas are militant about natural birth, and discourage their clients from seeking out pain relief, even if they want it.

I have been in situations where a woman is working really hard to birth her baby without pain medication. This is what she has asked me to help her do, everything is going normally, AND she happens to be making quite a lot of noise in the process. I have had medical practitioners demand to know why I am holding my client to this choice, have had them get in my client's face while she`s contracting asking her, "is anyone telling you you shouldn't take the epidural, because I think you should," and insisting the woman needs an epidural because she is "out of control" despite the woman telling her she doesn't want one. Please do not demonize the doula for your patient processing her labour powerfully. This is just the way some women are, and their vocalizations, tears, and complaints in no way mean they are not doing a stellar job birthing. It just means this is how they release tension. The image of the perfectly relaxed, quiet, patterned breathing lady as the gold standard for "good" natural labour must be shattered. I have birthed all my children naturally, yelling the house or hospital down with each one, begging for someone to "get it out!" and have never regretted not taking medication. I didn't need to be saved, I just needed to fuss. Natural birth is not some uber feminist political activity. It is a process many women wish to embrace, and are interested in going through it the way Nature designed it, which happens to be a pretty intense design. Because she chooses natural birth doesn't mean she wishes she weren't in a hospital without her chosen safety net.. she simply prefers not to be part of the 98% epidurals for first time mothers statistic.

Disturbing her process because you assume it`s too hard for her doesn`t help her...it discourages and disempowers her. The only one holding her to task is her, even if we as doulas are actively encouraging her to keep on going. Trust that if she truly calls it quits, she will have our support...because we know her and this has been communicated between us before you`ve even met her, we are supporting her the way she`s asked us too. Sometimes you will see our support is to help our clients get epidurals as quickly as possible if this is their intention. Our clients vary a lot.

3) Because doulas don't attend as many deliveries as medical professionals, they cannot possibly have enough experience to offer.

Though it is true the volume of "deliveries" attended by medical and midwifery practitioners are and will always be far greater than those doulas can attend, you have to remember the HOURS we spend with each client create a lot of opportunity to properly witness and interpret, without clinical responsibility, the unique way in which birth unfolds for her. We have learned a lot about supporting birth, through experience you many not have, by witnessing birth at home, birthing centres AND hospital, often all the way from start to finish. I have insight into this process you may not because your time is divided and your observations are intermittent. You may have a 12 hour shift in which you visit periodically, whereas I am there the whole time, on occasion even for 48 hours in a row. I do the postpartum follow-up, and if I am blessed to attend the next births of these clients, I know them very very well. You need to trust that we KNOW our ladies. We know what they want, what they are afraid of, how they have been hurt in the past, we are keepers of some of their deeper secrets and quirks, know what words NOT to say, and have usually watched the way they labour at home before they get to the hospital. You might need to go out on a limb and have a little faith that even though you have more knowledge and experience regarding management of labour and delivery (and thanks for that..we are grateful you are there for the work we are not qualified to do), we may have a greater understanding of the flow of THIS labour and the personality/emotion/energy of the one who this labour force is being channeled by.

I have noticed a few nurses, when they find out I am a doula, get a little territorial and start wanting to "show" me their support skills (most don't...they just leave me do my thing and do their job), asking me why I`m not doing or not doing something they know to be labour support, assuming I`m bad at my job. And occasionally, in doing this, they provide support that is inappropriate to the client/patient we're tending to. For example, I have lots of women who tell me being too hot makes them nauseated, or that they hate being touched when they're in pain. From the many hours we have spent together prenatally, I know this. Seeing me NOT using heating pads or massage, or birthing balls, or directive breathing as labour support tools on occasion does not mean I am ignorant of them or too lazy to apply these techniques. It means I probably know this is something the client has intuited she won't want during labour. If a nurse walks in and starts telling my client ways to breathe or move or tools to use simply because it looks like I`m doing nothing, she may essentially be flooding the labouring woman with too much information in the moment, which draws her out of her deepest mammalian brain, and actually impedes the flow of labour hormones. Sometimes a doula's magic is about being still and quiet, simply being a resource a client can look at for a smile of reassurance or someone trusted and familiar she can reach out for when she needs. Essentially, we hold the space.

This does not mean I don't value a nurse's or doctor`s input! Ì am not saying they should leave all the support to us. I honour a nurse`s experience. If she says, "Hey, I have an idea!" or jumps in because she knows in any given situation a particular tool will almost always help given the huge amount of experience she has, I welcome this knowledge wholeheartedly, and thank those who are willing to help me learn. They are clearly coming from a place of good authority in this instance, not ego. I don`t hold the belief that medical people cannot offer fantastic labour support..they certainly can at times. I personally have been held in the arms of a family doctor while she slow danced with me in hard labour while I cried into her comforting shoulder about what a hard time I was having.

My clients have hired me as their constant and trusted support because they know it is intermittent at best at a hospital. It`s just the way the system is. Don`t take that personally. Knowing someone is there to make womens` labours more comfortable in the absence of a medical caregiver should make nurses, midwives, and doctors relieved, not wary.
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4) Doulas tell their clients they can have a hospital birth without any interventions with their guidance.

Not true. We understand that by being in the hospital, we're in your house. I know your level of responsibility, I truly do, and I honour the work you do. If my client doesn't want to be monitored at all, I know this is unreasonable to expect. I will suggest monitoring in a comfortable position for her, or ask if monitoring can be more intermittent, but I won't lead my client to believe they can just easily go without monitoring or vaginal examination in the hospital. If my client decides to sign a waiver stating she is going against medical advice and refusing these things that are policy, PLEASE know I did not "put her up to it". It is often our clients who hire us because THEY are anti-hospital and feel they need someone to help make their experience palatable within that system. I actually try to help veer couples from this kind of thinking. I don't think it helps people to go into a hospital assuming they are going to be victimized. I don't want my clients to mistrust their doctors and nurses. I think this mistrust leads to a guarding of oneself that doesn't lend well to birth flowing smoothly. If a pregnant client doesn't get along with her caregiver, I suggest changing caregivers to one I can refer her to who I know is compassionate and respectful. If she is not willing to do that yet is willing to complain loudly about the disliked caregiver she refuses to leave, then I consider this a reflection of deeper seated issues I will be very aware of during the birth.

Our clients CHOOSE hospital birth, most often because this is what they want. To an extent, if they make this choice, they claim they are willing to jump through some of the required hoops and ride out some of the inconveniences as the price of the safety they feel they are buying from being in this system. To help them understand the reality of the system and what choices they may have to make in different situations is important, as sometimes in knowing, they are opened up to different realms of choice. But this is normally not done by doulas in a way that makes clients feel like they`re going on a suicide mission. Doctors and nurses should never be demonized, as these are the people who will be their caregivers. There has to be some trust in good intentions. In my experience, doctors and nurses are very much invested in their patients not only having a medically safe experience, but also a nice one. No good medical care provider is going to feel good about their patients feeling awful. When a woman has a birth she feels great about, everyone in the birthing room is really happy.

For a doula to lead her client to believe she will have a homebirth like experience in a hospital, especially by means of putting up a huge fight and mistrusting the establishment, is misleading and potentially wounding. We`re honest about the challenges, but we don`t tell them to approach medical personnel with viciousness. We are not about making enemies.

5) Doulas are totally against medical intervention in birth.

I have seen way too much for that to be true. I am not some wide eyed, naive, girl with flowers in her hair just because I work under the title of "doula" (which, but the way, I actually think is a silly name...not a fan of it, but it's so entrenched in the vernacular, what're ya gonna do?). I have seen fetal death a couple of times. I have seen ruptured uteruses. I have seen prolapsed cords and babies come out looking terrible without any apparent reasons. I`ve been at this for a long time, yet these instances are so rare, I easily manage to keep my belief that birth works great most of the time. I believe all interventions hold inherent value when used appropriately. And who am I to say whether or not the intervention is appropriate? If a woman chooses to birth in a hospital and agrees to follow her doctor`s advice, it`s not for me to assume she`s making misguided choices just because it`s something I may not choose myself. Just because a particular intervention may not be lavender scented or perfectly natural doesn`t mean the knowledge,technology, or medicine wasn`t whispered down by the same Source that motivates a favoured doula skill.

I'm not a medical person or a midwife, and I'm not out to endanger anybody by assuming I know much about clinical care. But I do believe in asking questions. If a resident comes into the room and tells my client that because she's been at 3cm (gently contracting) for a few hours and needs some Synto stimulation, I won't jump in and say, "No she doesn't!" and reach for my homeopathic remedies. That`s disempowering. After all, she may WANT the Pit. But I will ask my client how she feels about it, and suggest she ask if it's the resident's suggestion or if there is a real, immediate worry about the baby. I remind my clients who, like many people, are in awe of medical professionals and a little afraid to appear stupid by asking questions, that medical people are humans, and in my experience usually very willing to respectfully explain the suggestion/request/demand. The vast majority of doctors don't automatically assume they're being questioned or cornered because someone asks them a question. If a doctor says, "I'm worried about this and this and in my experience this and this can happen if we don't do this and this," this gives the woman information with which to choose. If I have questions of my own, I'll ask them, and if a midwife or medical person takes the questions personally, that is a reflection of them, not of me. My respectfully put questions are intended to gather information and learn, not a knee jerk reaction to criticise or negate a clinical call.

Now, I have had some pretty intense encounters with doctors. Some hate doulas on sight, and will take our presence in their house very personally. I had a doctor who seemed to think I was "protecting" my client from their ``evil ``vaginal examination because I held her hand and guided her to breathe in and out gently before their fingers were introduced. They said, "You act like you're preparing her for the worst." and I could just hear the anti-doula alarms ringing. I was actually preparing her not because I thought they or their exams were evil, but because she had told me in our prenatal encounters that her cervix was very tender and has always experienced terrible pain with examinations. After that, things just went downhill. Because this lady was standing up a lot and was receiving intermittent monitoring at her request, the doctor was sending out the vibe they thought these clients were anti-hospital birth and were using me as a resource to tell them what to do. The doctor started making comments to them like, "You know, in obstetrics it's not about what YOU want." These clients were not children who needed lecturing and of the mindset that birth should be natural at all costs! They were not asking questions because they were anti-doctor, yet they were being treated as if this were the case, and the level of tension in the room was terrible. Sadly, she never dilated beyond that point, and could just not get her mojo back. What makes me sad is that I've had great births with this doctor in the past. What I'm thinking is that this person may have witnessed some pretty bad doula behaviour for them to formulate such a strong reaction over a slight that didn't even exist. For that, I feel sorry, as if I need to apologize for all those of my kind who step on toes and enter the hospital with a bad attitude. At some point, I hope this doctor learns to trust me, knowing if my clients are not on IV or monitor all the time or ask questions, that it's emphatically not because I set out to sabotage their approach to care. I am not so powerful that I can pull those kinds of puppet strings, even if I wanted to.

I will be the first to congratulate a client for choosing an epidural if she felt she was suffering with her labour for whatever reason and was no longer open to my suggestions, or jump in with getting her on her back with directed pushing if that's what she says she wants or proves useful to her. If a client is vomiting and clearly becoming dehydrated and nothing we try alleviates this, if a medical person starts talking about IV, I gently validate the value of IV hydration in cases like hers, even though she may have been desperate to avoid that intervention. It's not that I am trying to get her to choose that, but to perhaps buffer some fear around it. If a mom is going to choose in intervention, the last thing I want is for her to be in mortal fear of it. It won't work as well. As a doula, I have to give both sides of the story without bias. This way a woman can truly choose as opposed to being led somewhere according to my personal bias. And remember, I am dealing with women here who are choosing to birth in a hospital, meaning they DO have an underlying fear a lot of the time of all hell breaking loose in labour. They are there because they want options and feel safer knowing there are shiny machines that go "ping". Homebirth is a whole different kettle fish, and the beliefs about birth for women who choose this setting are not generally coming from the same gestalt.

6) Doulas believe that if a client is informed and does everything "right", she will be rewarded by a wonderful birth.

Just because we are helping a client who wishes to minimize interventions where possible, does not mean we are subject to magical thinking. Please give us more credit than that. The one thing I emphasize to my clients is that birth is unpredictable. I encourage flexibility. I help them to be able to ride waves of any nature, not just the lovely natural birth ones. I don't see a C-section or epidural as some kind of personal failure. It would be terribly cruel to project that kind of perfectionism onto any mother. In fact, I find the couples who are the most easy going, the ones who are committed to natural birth but are open to intervention if necessary or if it becomes a personal choice, tend to have much better overall birth experiences....far better than those who write super detailed birth plans. It's the people who are totally attached to natural birth no matter what, who assume they will feel like failures if things don't go the way they want, and who are judgmental of those who are too "unaware" to eschew these interventions, who often end up being quite disappointed in their experience. I don't mean to get esoteric here, but it seems the more you try to hold onto control during labour, the more it tends to veer away from you. The Great Lady Birth doesn`t like to have assumptions made about her. It's great to hold a hope and an intention, and I fully support someone sayìng, I`m going to go all the way for a natural birth!``, but I do feel having the flexibility to move to Plan B is a great resource.

This is not to say that flexible people do not get wounded in birth...a bad environment, unanswered questions, lack of respect and compassion, and lack of knowledge of options can definitely create birth trauma, as can just a really rough natural birth. This is where doulas come in...to help that kind of trauma not happen. An unexpected C-section is usually a lot easier to heal from if there was respect, information, and loving words. At least a woman is not left all alone in the dark thinking, "my body must be defunct." This is a hard wound for a woman to bear. As doulas we have tremendous power to connect a woman to those areas of her birth she shone and was really strong and amazing, even if things went unexpectly. We believe happy mothers who feel great about themselves provide calmer, happier care to their babies, so their feeling as good about themselves even in light of a harsh experience is crucial to healing.

What I can tell you, is that I believe most of the time birth works really really well, and while I as a doula cannot recreate Ina May`s Farm, with a combination of good clinical care (midwifery/medical) and good supportive care (doulas), we provide what parents feel is the best of both worlds. In doing so together, we CAN reduce the rate of unnecessary interventions, have the world populated by happier, more emotionally connected parents, and have healthier, happier, more emotionally connected babies. It's not a bad goal.

Doula work is mostly joyful, and most doctors and nurses I know like their jobs a lot too. If this were a profession that caused constant trauma and heartache, I personally wouldn't do it. To witness the birth of a child into the arms of an ecstatic mother and father or non birthing mom is one of the most enriching things I can imagine....and I get to see it much of the time, even, yes, in hospital birth where most of my clients choose to have their babies.

I hope I have shed light on some of the ideas people have about doulas, as well as explain some of the challenges we have given common attitudes about us and our work. I know this list is not complete, but I hope it gets some good dialogue happening.


Lesley
http://www.motherwit.ca/