Thursday, June 3, 2010

Patient Interest or Witch Hunt?

I had a lovely birth at St. Mary's Hospital early this morning. This baby was truly a miracle in many senses of the word, and it was an amazing honour to support such a powerful, triumphant experience. To know I am a positive part of this precious memory of birth is the deep reward for being a doula.

After the baby arrived safely, the nurse, whom everyone enjoyed as a strong, supportive, incredibly experienced presence, asked me to leave my name at the nurse's desk. I admit it was about 2:30am and my faculties of information retention may not have been at their best, but what I understood was that people who were coming into St. Mary's as doulas needed to register their names. This was news to me. It is true that St. Mary's is not the hospital I work most frequently at, perhaps only attending 10 births a year or so there, but I had not heard of this request before, neither personally nor from my doula colleagues.

I jokingly asked the nurse if I was about to be blacklisted, or if alarms and whistles would go off if I walked into Saint. Mary's again. She said they had a new policy to know who doulas were, because they were no longer allowing "medical management" of birth to be conducted by doulas. I said, "But doulas aren't qualified or allowed to manage anything medically!" Her expression was kind, but made it clear that the phenomenon of doulas behaving badly was alive and well at her place of work.

On the one hand, I most certainly do agree that medical staff should not have to feel medically challenged by a person who is supposed to be providing emotional support and comfort measures for their clients. This is not safe for anyone. I feel very badly for the staff who work extremely hard, have protocols that are part of their job description to follow, have the weight of immense responsibility for the well being of a mother and child on their shoulders, then have to deal with a naysayer in the room whose modes of advocacy are combative, and therefore unwise. If a doula's attitude is negative towards the staff, breeding mistrust in her clients for these caregivers, leading them towards choices based on her personal agenda rather than helping them make informed decisions in light of what the staff deems medically necessary for their care, then yes...it makes sense the staff would want to know about this person and set limits on behaviours that interfere with their responsibilities.

But on the other hand....

My name was taken down not on any official form that would reflect this was an established hospital policy, but on a scrap of paper. No phone number, email address, feedback, nothing. Just my name on a little square of paper. Now I wonder what will happen to my name. Will I be Googled? Will they talk about me in the nurse's station? Will they grill my clients on their level of satisfaction with my services? Will they pick through all my behaviours that were annoying to them, blow them up into monstrous proportions, and then put me on the black list so that when I next walk through the doors of St. Mary's I will be met with the stink eye by everyone? I have to say, I am concerned.

Of course, my first thought was to go over my behaviour. It is always very important as a doula to constantly review where we can improve. My clients seemed to be very happy with my services, as I helped them to have the un-epiduraled birth they were dreaming of. So how did I do this?

1) My client had to have an I.V. for medical reasons, so I asked the nurse (not the same one who took my name) if a saline lock could be put in so she could walk around. Remember, I spend a lot of time with my clients prenatally, and get to know what would help them, given their personalities and concerns, cope with the challenges of labour. There was no doubt this lady needed to move a lot of energy by walking. The nurse said this would be no problem. It wasn't offered as an option, but upon my asking, it was kindly given. So walk my client did...with more energy that I had, not to mention a few trips up and down stairs, which would have been impossible with an I.V. pole. The monitoring devices were wireless, which allowed for free movement, so it only made sense that not having to march around with a heavy I.V. pole if not medically necessary at that time would make my client more comfortable. St. Mary's is a hospital which embraces the Baby Friendly Initiative, and I figure empowered birth must be an aspect of that initiative, given there are textbooks on the subject of the impact of unnecessary medical interventions on breastfeeding.

2)My client wanted to avoid labour stimulation. Due to existing circumstances, getting labour going was an important goal, so I used lots of acupressure and aromatherapy, which really seemed to help pick up contractions. Eventually, some synthetic oxytocin was ordered by her doctor, and I in no way got in the way of the staff doing what they had to do in that regard. That is beyond my scope of practice. The stimulation was absolutely minimal, and resulted in an un-epiduraled, beautiful birth.

3)My client wanted to be free to be in whatever position she wanted, but when it came time to push, her doctor was not immediately available, and it looked like the nurse would be catching the baby. She put my client into the traditional position, and as my client didn't argue about it, I didn't feel like saying, "Hey, you said you wanted to be in another position...are you sure you want to be on your back?" would enhance the situation. I felt it was important for the nurse to be comfortable with what she was doing, as she was put in the position to be responsible for this situation. My instinct was just to be silent and to trust my client would speak up herself if the position was not good for her.

4) I could tell my client was NOT liking the yelling at her to make no noise during pushing. She was vocalizing powerfully, and her baby was moving down. In fact, the baby moved down and out in 12 minutes, most of the time with her mom bellowing. I never direct pushing unless it's asked for by my client, or she is very scared to go into that downward sensation and a little encouragement to bear down to push some of the tension away would be helpful, or it is made known the baby truly needs to come out quickly and focused pushing is necessary. The reasons I try to remain quiet are 1) There are enough frighteningly loud voices in the room contributing to the Purple Pushing Party. 2)With a baby coming down that straightforwardly, it makes little sense to me to make a mom feel criticized for how her body is naturally and spontaneously expelling her baby. I have personal experience of pushing with no direction. I know if she were birthing unassisted accidentally somewhere, nobody would tell her when or how to push. It would just happen, and the VAST majority of the time Baby would simply emerge, Mom yelling or not yelling. I don't buy the argument that a woman will get more exhausted by the second stage being longer if she is doing what comes naturally as opposed to making it fast by expending eyeball popping effort. Yes, we know on average purple pushing makes the baby come 13 minutes faster, but evidence suggests to me, granted this being merely anecdotal evidence, as I'm the one who follows up with the mom postpartum at home, that she's in better shape when, if possible, she directs her own pushing.

Now it's important to note that while this is my personal opinion, I didn't state it out loud. There's no room for naysaying in a birth or ego centred battling over a client's body. I didn't request anyone stop directing. At some point my client looked at me at and indicated she was not enjoying being yelled at, that her vocalizations felt good to her, and I just winked at her and whispered that she was doing beautifully and that her wonderful efforts were making us see the baby already. Those words made her realize she was not actually doing anything wrong without criticizing anyone else in the room.

5)My client was interested in the baby latching on by herself by doing the breast crawl. St. Mary's is very supportive of constant skin to skin contact after birth, and it was a lovely, gentle environment for this new being in the world. Sadly, as the breast crawl often takes more than the hour or so the mother is left in the birthing room to recover before being transferred to postpartum, it is often unrealistic to be allowed to wait this amount of time. This sort of diminishes the Baby Friendly aspect a little, as the W.H.O. seems to very much support infant initiated latch. So if there isn't enough time to do it, then this crawl must be interrupted so the baby can at least get a suckle in before they have to be transported to postpartum. Not ideal, but as the beds are being waited for by labouring mothers in the hall a lot of time, C'est la vie. Baby was very alert and by being placed closer to the breast, she found it and latched on her own anyway, in a biologically nurturing position.


6)My client did not want drops in the baby's eyes until after feeding was initiated. The nurse was about to put them in the eyes and I asked what the window of time was, as every hospital seems to have a different policy on this. The nurse said it has to be done right away when there is GBS. I didn't argue, as this was again not a huge issue to begin discussing, but I have had doctors tell me the drops don't affect GBS, that they are only really for possible STIs. It is difficult to know what to do when the information I receive from various sources is often conflicting, and as the parents at the time weren't too worried about it, I let it go. Parents in the end want to remember peaceful contact with their newborn, not battling opinions.

7) In postpartum, when the baby was about to get the vitamin K shot, I asked if she could be at the breast while she was receiving it. This was not offered as an option, but was happily provided upon asking. The parents were very glad for this arrangement, as suckling releases endorphins and calms the newborn, thus reducing some of the pain of the injection.

All this is to say is that I feel I walked the line appropriately of advocating for my clients' wishes in a positive, friendly way, and not getting in the way of staff members trying to do their jobs.

Taking down my name on a piece of scrap paper makes me feel scrutinized. I am not worried that I did anything to endanger my client's or her baby's health, but what does worry me are the implications of this "policy".

All of the staff I worked with were kind and respectful of my clients' experience to the best of their knowledge and ability. They were kind and respectful of me too. But what if a doula coming into St. Mary's is just doing her job the same way, but for some reason her personality or approach rubs a nurse the wrong way that day, even if she's not actually doing anything inappropriate? What if a nurse is particularly sensitive to perceiving criticism when a doula is supporting her client a certain way and the client is more responsive to the doula's support than the nurse's, and the nurse gets upset? What if the staff believes the requests and "rebellion" of the couple are being generated by the doula herself? Remember, just because a patient is challenging doesn't mean the doula should be made scapegoat. If a client squats on the floor and starts birthing, or pulls out her IV, or refuses to get on her back, it doesn't mean we've guided her to do so.

I don't believe for a second many of us are as bad as we're made out to be as a group. Yes, there are undeniably a few bad bananas in every bunch, as there are in hospitals. This doesn't mean each doula should be demonized for every little inconvenience that comes up for the staff, or be judged unfairly because the last doula who was at the hospital happened to be a nightmare and everyone's still reeling from that experience.

The bottom line is the role of doula is bequeathed to us by the parents themselves. They understand the hospital system can be big, unfamiliar, overwhelming, and with unpredictable service. We don't come storming in bringing our clients with us to prove a point. We are there because your patients hired us privately to be there, knowing that in labour they may be too vulnerable, occupied, or unaware of what their options are to achieve their greatest comfort. Yes, that is a criticism of your system. But you know it yourselves. Don't blame the doula and project onto us your judgement that we embody this criticism, are there to make your lives miserable, and to make our clients our own personal political projects. A good doula wants to bridge the gap between the solid clinical care and technology you provide, and continuous one on one support and advocacy, which, sorry to say, means we will ask questions in order to facilitate the best experience we can for our clients. I will not do this in a way to make you feel that your patients are endangered. I respect your knowledge and experience. I will honour your medical choices, but I will at times, if it is appropriate to the situation of my client, question the evidence of some traditions and statements, and request things that may not always be the most convenient for you, like saline locks and intermittent monitoring while a client sits on a ball instead of lies on a bed. You may notice me being very different from one client to another. This is because we advocate the CLIENT'S wishes, not mine, and all clients have different needs and wishes.

My career and livelihood depends upon my being allowed into the hospital system. This is not just some little hobby of mine. I have spent almost 19 years developing myself and my skill set to be a doula to the best of my ability. To become blacklisted because someone's ego was bruised one day, or because someone misinterpreted my question for my client's sake as a personal attack, or if my client locked herself in the bathroom and gave birth without my having any clue she was going to do that, crosses the line between claiming safety for patients, and a blatant witch hunt.

Doulas, I think it is really important when you go to St. Mary's Hospital to ask to officially see this policy on paper, and to have everything explained to you before you give your name. I was very busy, and didn't manage to do this. My sense and fear is that even if you work within the scope of doula practice, doing your best to be as nice to everyone as possible, you might be misinterpreted, someone might get mad at you, and poof, there goes your ability to work at St. Mary's. Not to condemn a hospital staff as a whole, but there might be some people who will dislike you immediately simply because you ARE a doula, and will interpret every question, word, and action as a criticism or threat. I have seen this. It is certainly not the norm, as I find the vast majority of people give us the benefit of the doubt if they don't know us. But what if you get unlucky? I want this policy to be extremely clear, out in the open, publicized, doulas made aware of it immediately when they arrive, AND I want some assurance that our practices are protected from those who are unequivocally anti-doula. St. Mary's wants to be protected from doulas who are anti-hospital, and I understand this, but it needs to be a two way street. Whether or not our presence is appreciated by hospital staff, our popularity still grows, good birth outcome stats still rise with our presence, parents still love us, so, friends, we ain't going anywhere. My spidey senses tell me clarity and forthrightness about this new policy needs to happen before gradually all of us doulas who work tirelessly to create a legacy of gentle, lovely, humane hospital birth are, so to speak, burned at the stake.