Sunday, April 4, 2010

Memories of ALACE

I was checking out Association of Labour Assistants and Childbirth Educators (ALACE) online today, just to reconnect and see what's going on with them. They are now called tolabour. They have been around since 1983. I took their training in 1993 when they were still called Informed Homebirth/Informed Birth and Parenting. I was attracted to them because the organization was created by midwives, obviously with a belief in the midwifery model of care, regardless of the primary caregiver or place of birth. They put a lot of emphasis on the emotional care of the woman, and constantly challenged the doula to figure out what she would do in any given scenario. My training manual was chock full of information, and there was a substantial reading list.

I absolutely loved my labour assistant training. I'm still not entirely comfortable with the word "doula" to describe my work, and "labour assistant" made people think I was part of a union or something, but I digress...it was a great step in becoming a birth companion. It was a fabulous course, taught at the time by midwife Catherine Stone, whom I still remember with great fondness.

What I loved about it, and they still continue to do this today, was the opportunity to do some hands on physical stuff. Not because they promote this as something a doula should do, but to get a deeper, visceral understanding of what women go through prenatally and in labour. I was taught to find fetal heart tones with a fetoscope for the purpose of identifying where a baby is lying, palpation, and basic pelvic examination. While I know this may make some doulas squirm with discomfort, let me reassure you for a moment. I do not do pelvic examinations in my practice. For one, learning how to examine the cervix of a woman neither pregnant nor in labour is not at all teaching someone how to check how dilated someone is. This would take a lot of hands on training in the field, which is obviously beyond the scope of a doula's work. The intent behind this exercise was for us to get a feel for this cervix thing we talk so much about. How empowering it was, within a safe environment with a certified midwife, to get a better understanding of the landscape of the female pelvis via the vagina! I know what an ischial spine feels like now and I truly understand the mobility of the coccyx. My fingers will never forget that sensation! But most important to the learning, especially for those who maybe had not had children before, was being in a position to be on the receiving end of the exam with onlookers. I think this is what the exercise was mostly about....to gain empathy and to receive the support of the student doula holding our hand and guiding us in relaxation.

What people need to know is that learning a basic pelvic exam is not in any way, shape, or form a licence to check a lady's cervix during labour. While some may argue, "Well, an oncologist doesn't need to have had cancer to be excellent at what he does, so why would you have to know what a cervix feels like to be an excellent doula?" Good question. You don't. I don't think you need to have done or received an exam or even had a baby to be a fabulous doula. But like the oncologist who is also a cancer survivor, with a little personal experience, some depth is gained. There is a difference between gaining empathy through hands on work for experiential purposes and giving permission to diagnose a cervix in labour.

I continue to palpate bellies and stick with belly mapping, which I find is an empowering exercise for a mother and her partner to connect with their baby, and for the mother to remember to maintain good posture if she notices the baby's back shifting throughout the day. I have owned my fetoscope for 18 years, and on the odd occasion, if we're not convinced of where the baby is, I might show the mom how to find the heart it if it's possible. I often leave my fetoscope with the family so they can listen to their baby once in awhile. Mothers of twins love this! It has been through many sets of hands and heard many heartbeats. I do not think this is "diagnosing" or doing anything clinical. Check out spinningbabies.com created by Gail Tulley who is a midwife and DONA certified doula for more info on belly mapping. I NEVER have and NEVER will look for fetal heartones at home during childbirth, because that crosses the line between empowering parents and clinical care.


The question my clients always ask is, "If you are with me at home, how do we know when it's time to go to the hospital if you don't check my cervix?" As a doula, I find this is an easy question to answer. I observe the mother's labour, and rarely look at a clock. I don't generally time contractions. If things are getting much stronger, we usually know without a clock telling us that the contractions are longer and closer together (in most cases, but not all). I listen to her breathing and sounds. I check for the obvious signs of endorphin release written on the mom's face. When the mom begins to seem like she has gone from early labour to "active labour" according to our combined maternal/paternal/doula spidey senses (which I don't think has much to do with a number of centimetres, as I have had women who are in extremely active labour when the doctor tells them they're 2m, as well as women at 8cm who are still hovering on the fence between early and active labour), we go directly to the hospital. And what if we are proven wrong at the hospital, that labour is indeed still early? Well, we haven't made a mistake. Because if the mother is having what appears to be very strong contractions she can't speak through and looks all stoned between them (endorphins), the contractions seem long and quite frequent, then moving to the hospital where the baby and mother will be monitored by her primary caregiver at whatever interval they feel is appropriate is important, no matter how much longer there is to go in the labour. Of course, if a client wants to go before or a bit later than this guideline, that is her choice, but I make sure they understand the information surrounding each choice. So far, I've never caught a baby in a car :)

My doing a vaginal examination to try to figure out whether or not it is a good idea to stay at home longer could be potentially detrimental to the mother and baby. For one, I stand by my claim that a number doesn't mean much. We experienced birth attendants know how changeable a cervix is. My trying to figure that out and come up with a magic number only puts the mother in a state of more discomfort, and my "judgement" may potentially keep her from the hospital when it's a good time for her to be there, having the baby listened to now and then. If labour looks active, even if it's technically not, a midwife at a homebirth still listens to the heart tones periodically. A woman chooses to have a hospital birth because this is where she feels she will be safest, and this is where she receives the clinical care that determines her and her baby's well being. Staying home with just a doula for a very long labour, especially since a doula doesn't listen to heart tones, is not usually something a client would choose to do when properly informed about the doula's scope of practice. It would be different if that doula was also a monitrice, but I am personally not one. That's a responsibility I don't want.

So thank you, ALACE, for providing me with the tools for the long and satisfying career I have been enjoying. You ladies are AWESOME!