Thursday, October 21, 2010

Doulas Teaching Doctors

I am so grateful to have had the opportunity to do a little workshop yesterday with medical residents on the role of the doula in childbirth, and how to help a woman deal with the strong sensations of the second stage of labour.

Just to give a bit of a background: I work at all the hospitals in Montreal pretty much, and have always tended to favour the birth experiences in which family doctors are the primary caregivers. For one, I see a lot more consistency in their practices. If the woman's doctor can't be there, the one who is on call tends to have a very similar approach, and she isn't shocked by a radically different philosophy that sometimes exists between one obstetrician and another. I am of course generalizing, however I do see a strong tendency towards consistency. Consistency builds security, and security contributes to better birth experiences.

Another reason I enjoy births in which family doctors are present, is that they tend to have a much more relaxed approach. In Montreal, I see more babies caught in the hands and knees position by family docs than I do with their moms in the stranded beetle posture. Family doctors tend to hang out in the labour room more, building rapport. I also generally find they encourage questions, respect concerns, do their best to answer questions, and are invested not just in a good clinical outcome, but in the emotional well being of their patients too. Plus the continuity of care is attractive to many couples. Often the same family doctor who took care of them prenatally will take the baby on as a patient too...perhaps even all the family members. In a city where finding a family doctor is nearly impossible, this is an appealing option for medical care if indeed a hospital birth is desired, but with as little interruption/routine procedures/sledgehammer obstetrics as possible. Not to knock sledgehammer obstetrics...it certainly has its time and place, and thank goodness for that. But many women want a low tech birth even though they are not comfortable birthing at home or at a free standing birthing centre. For these women, the care of family doctors provides them with what they're looking for.

A nice thing about the family doctors I've worked with over the years, is that they are generally very supportive of doula care. Because of this mutual appreciation and respect, the birthing environment is usually really nice for Mom and her partner. No, it's not home birth for all you readers who don't feel safe or like birthing in a hospital, yes, there are still strangers, shift changes, and not total control over your environment (in my town you won't get to birth in a bathtub or squatting over the toilet even if it's what you really want when it's time for the baby to emerge) and yes, there are rules and restrictions that are hospital policy no matter who the caregiver is... but as I said, for those who WANT a decent experience AND embrace the benefits of medical care even if it means following a few rules, the phrase "nice hospital birth" does not have to be an oxymoron. If I didn't often have lovely hospital birth experiences, I couldn't do my job. I'd be a depressed wreck.

What I'm basically saying is that my highest ratio of truly lovely hospital birth experiences takes place under the care of family physicians. In fact, my second child was born into the hands of a gentle, loving, encouraging family doctor after my midwife felt it was necessary to transport me to the hospital, and my one hospital birth experience was just fine. True, an impatient nurse literally made my exhausted midwife cry by blaming her because I was choosing not to stay on a monitor (I was not trying to be a "bad" patient, I had just been in way too much pain for too long to be able to stand still long enough to get more than a 30 second trace), but the doctors themselves were godsends. One of them actually slow danced with me through a few contractions. Her comfort with touch and willingness to use her body to support a woman in nutso labour is not something you see every day.

At the MotherWit Doula Training Intensive I gave this summer in Morin Heights, Quebec, I was graced by the presence of a lovely student who happens to do administrative work for the group of baby catching family doctors I like best. She had a lot of ideas about how cool it would be to do some doula-led info sessions to residents to help them learn how to appropriately and effectively be with a labouring lady.

At first I thought this was a great idea. A couple of doctor friends of mine, though, didn't. Both thought that time is so tight for residents, that learning now to hang out with birthing women and rub their backs wasn't going to be time well spent, that improving basic skills was much more productive...not to dis my profession, or anything. And truly, I heard that, and figured, "oh, true...good point". After all, that kind of "fluffy" stuff (that's how it's perceived, anyway) is my job, not a doctor's. I agree that a new doctor's focus is going to be on medical care, not doula work. However, after having now done the workshop and having reflected upon some experiences I've had with residents in the past, I am absolutely glad I did it and my suspicion that imparting a few simple doula tricks to medical residents would prove to be valuable was true.

To be an excellent clinician in no way means you automatically know how to approach birthing women with wisdom. Wisdom grows, and planting a few seeds is not time wasted. Yes, doctors needing to improve their clinical skills is crucial. But to be a doctor means to interact with patients, in this case vulnerable, open, life giving women who are having peak experiences of pain and physical/emotional catharses. Some manners to keep that experience sacred, if you will, are important to learn.

I have known of and seen residents do the following (please don't judge them harshly...they are learning, and most of them are young and sweet...they make me want to feed them soup): talk about the baby in the next room who just suffered from major shoulder dystocia while they are standing between the legs of a woman whose baby is crowning...answer and talk on a cell phone WHILE doing a vaginal exam...allow a discussion to unfold, inspired by the fact that the woman in front of them has been pushing for a long while, about the baby earlier in the day who died from a complication and that that mom had been pushing for a long time too....tell a woman that she CANNOT deliver unless she BLOCKS her air and GETS MAD at the baby and PUSHES it out HARD....examine a woman because she has had some mild bleeding and cramping and given what's going on with her cervix tells her in no uncertain terms that she will NOT go into labour on her own, will have to be induced, and that a natural birth will be impossible, and not to set herself up for disappointment (the lady birthed completely normally 6 hours later, by the way...I have known of this resident to say this to a couple of my clients, only to be wrong each time). This is but a small sample of many anecdotes.

So instead of us getting mad at them and irate about their insensitive treatment (and many of them are born with an acute awareness of others' emotional needs...we're just discussing a few who need to develop this awareness), why not get more pro active and guide them towards a bit more awareness of the quality of their presence? I believe in people's hearts, and I truly do not think any of these residents held bad intent in theirs. They are simply so busy learning how to be fantastic clinical care providers that it can be easy to forget that behind the pelvis is a woman and her partner...who are extremely vulnerable. The fact that doctors are entering into their practices NOT necessarily having been taught Ina May's words to live by: "If a woman doesn't look like a goddess in birth, someone isn't treating her right," means there are major gaps in medical training. Because as midwives and doulas, we are acutely aware that labour can malfunction when a mother becomes physically and emotionally distressed. Labour can stall. The sensations become more painful and make it much harder for a woman to embrace them. They can panic. It is not a wonder that lots of doctors don't view birth as beautiful and transformational, but as an act of suffering. Most doctors I know claim they will probably want an epidural when they themselves give birth. Most of the births they have seen have not been normal.

If the quantum physics theory (and obviously I'm being very general here) states that the observed "object" changes given how it is observed and by whom, Ina May may has hit the nail on the head. Be calm, present, aware, and respectful of the sacredness of the birthing woman's work, and maybe, just maybe, the quality of one's presence can influence the mother's sense of well being, thus creating a greater potential for smoother physiological functioning. It sure doesn't hurt, does it? Midwives and doulas believe and embody this belief, and act accordingly. Doulas do not just rub backs, suggest positions, and have our clients just talk about their feelings with us the live long day. We actually hold an energetic space...a strong, loving space within which a mother can birth confidently and hopefully as normally as possible. And if it doesn't work out that way, the benefit of our support is just as important, if not more, to keep her feeling strong and centred. I think this is the magic inherent in our better than average outcomes. Given the much studied and well documented fact that a doula's presence in the birthing room can, quite simply, make birth go better, I believe we have a lot to teach.

A few weeks ago, I was asked to show up on a particular date, but didn't have any information about what I was supposed to talk about until 2 days before the scheduled workshop. Then two days ago I received an email. The email basically said, "talk for 5 minutes about what a doula is and what she does, then for 25 minutes provide some concrete techniques for pain control in the second stage of labour. A doctor will talk more about pain control for about 10 minutes, and then there will be a question and answer period."

Give me a birth related topic and I can talk about it for hours, so I just jotted down a few notes. As I got closer to the building the workshop was being held in, I began to get a bit nervous. I don't normally get nervous anymore before teaching or public speaking, but I was feeling antsy. I walked into the room, feeling more confident because some of my MotherWit colleagues joined up with me, and was pretty surprised to see how many residents were actually there. More nerves. The family doctor who was facilitating this workshop was finishing up teaching about communicating with women they suspected were in abusive situations. Finally, it was our turn to speak. A few of the residents there had never heard of a doula, so we talked about who doulas are and what we do, and why what we do works.

To make a long story short, as I've been blathering on for long enough, we discussed the fact that though I was asked to talk about "pain control", I couldn't do that, as doulas don't do pain control, that in fact if a mom wants to birth normally, trying to control her pain could actually affect her progress. So that led to a discussion about the benefits of labour pain, which are probably not extolled as a virtue in medical school. We help moms embrace their sensations, work through their pain and provide the comfort measures and emotional support to help them with that task. Of course if they need or want pain control, we stand back and embrace anaesthesia too. We talked about how doulas don't really have an agenda about how a woman gives birth, but that we are invested in her feeling as powerful about her experience as possible.

Then I talked about oxytocin. A simple thing that residents can do to make birth more comfortable for Mom is to respect that the oxytocin/ endorphin interplay is fickle, and that things don't function as well when people are not respectful of the birthing environment. I asked them to imagine what it would be like if they themselves were trying to have a major poop, and people kept knocking on the door, asking how things were going and telling them the clock was ticking. Keeping that in mind, I asked them how it may feel to be a labouring mom who is experiencing some crazy sensations, feeling like a watermelon is in her rectum, is put on her back so strangers can see and touch her privates, and yelled at to PUSH! What might the mojo feel like to her? We talked about being wary of talking about other cases while in the presence of a birthing woman, or making her feel negatively judged, etc. We talked about oxytocin as being "zee 'ormone of looove", and that the more oxytocin, usually the more endorphins, which will contribute to helping a mom deal with her pain without us having to do much.

We talked about respecting physiology...why birthing on the back is, for most woman, probably a lot more painful than doing what feels natural, which is using gravity and utilizing the mobility
of the sacrum instead of sandwiching it between the baby's head and a bed. We talked about purple pushing...y'all know my views about that. Sesch and Lewina (my sister MotherWitties) and I demonstrated different pushing positions women seem to like. I passed around pictures of a woman giving birth on hands and knees and showing how a sacrum allowed its full range of motion will sometimes result in the baby's posterior shoulder coming out first. We showed a video clip of a woman birthing unassisted making the most powerful, loudest, beautiful-est, guttural noises you have ever heard, showing that no, purple pushing in normal birth is usually not necessary.

Sesch, Lewina, and I demonstrated how the residents could help to facilitate relaxation by centering themselves, speaking calmly, using reassuring touch and gentle guidance to help talk a really frightened, freaking out woman off a ledge. Sesch is fantastic at playing a stressed out birthing lady, and she yelled out while crossing her legs and drawing up her bum, "I HAVE to POO. AAARRRGHHH!" while I did the doula thing and calmed her down between her "contractions" and provided reassurance. We actually got a big round of applause for our role playing.

The doctor who was facilitating gave great feed back. She reminded us to talk about how to support women who were on epidurals, and also asked us to discuss how they might support a mother who has been sexually abused in her past. Interestingly, she also asked us how on earth we managed to have private lives given all the doula work we do. That's a whole 'nother blog. The best answer I can give to that one is to have a partner as supportive of my work as mine is. I couldn't be me if I didn't have him.

It seems there was some miscommunication, as it had been this doctor's belief that we were going to talk about the first stage of labour instead of the second. But it didn't really matter. Hopefully we got some messages across as well as provided some entertainment. I like things to be fun. We did focus heavily on physiological, unmedicated birth. This was not because we don't believe in pain relief in labour when a mom needs or wants it, but because we live in a culture in which natural birth is considered radical. In their worlds it's a rarity to see normal birth. I hope that talking about it as if it is an every day occurance might create balance and an inspiration to support more women to have normal births. If these residents understand that natural birth is the norm for most of our clients, perhaps it might make them say to a woman asking them for an epidural.."you're doing a great job...I know you can do it." If medical people understood how much their patients look to them, and realized that those few words could actually help many moms get through birth normally, that moms just might think, "if my doctor thinks I can, then I guess I really can!", they would realize how much power they have to make a woman's birth experience feel really positive to her, even if it doesn't go the way she had hoped or expected. Someone having faith in you is always a nice thing. A dear client of mine told her doctor that what she needed from her (as well her medical care) was to know that she believed in her. These fledgling maternal hopes should be nourished with great tenderness. Doctors aren't just clinicians who take case histories, scout for complications and treat them with their skills and tools, but witnesses to a birth experience! How special is that? May they never forget the honour.

Thank you, residents, for listening. Thank you, Doctor H, for your support, and thanks, Gen, for getting it off the ground. Let's do more.