Thursday, March 22, 2012

Where the Magic of Doula Care Lies

When people ask me "How does this doula thing work? Why is it doulas are able to bring such comfort to the women/couples in their care and reduce rates of unnecessary medical interventions?" I have an easy answer. The magic of doula care lies in the relationship between the doula and her clients.

It is incredibly valuable for all people who work with birth to have basic doula skills. A nurse or resident with basic doula skills can have a tremendously positive effect on a woman's labour. Even if these medical professionals don't have continuous time to spend with the couple, bringing in a fresh bit of energy into the room when they come in for an exam, perhaps some soft, gentle words of encouragement, a demonstration of how Dad can rub Mom's back, or a suggestion of how to use a yoga ball can be a soothing balm to couples who feel up the creek without a paddle.

I often get the opportunity to teach hands-on skills to student nurses and occasionally medical residents too, and the positive feedback I get lets me know that learning about birth through the eyes of a doula can bring a fresh perspective. This means viewing birth from a larger framework than just clinical, having a solid trust in the normalcy of the process for most women, and having a desire to protect the flow of oxytocin, which contributes to optimal bonding for Mother/s, Father, and Baby/ies. Focus on numbers, dilation, and time are de-emphasized in the couple's presence (unless necessary), while the parents' comfort and emotional state are taken into consideration. Small things, like being aware that while this is just a day on the job for a medical caregiver, it is the most special day in the life of these patients, are remembered. Remembering that moms are not intellectual beings during labour and that more than the necessary questions and explanations can disrupt her labour, or that talking with others in the room may disturb her during a contraction are small things, yet go a very long way in protecting the moment to moment experience for the labouring parents.

For those couples, however, who do not have support from loving friends/family who are knowledgeable of how to support their unique experience, free from their own personal agendas of how their birth "should" be, there is no substitute for a doula. Continuous labour support from someone with whom the couple has spent some time prenatally and forged a strong relationship with, or at least with someone who is well aware of their unique needs before they enter the birthing room (as in a situation requiring backup doula care) brings about a deeper sense of emotional safety. With emotional safety comes more relaxation, and with more relaxation ideally comes a smoother release of all those great labour hormones. Doulas strive to build a relationship of trust with their clients. We ask questions like: "What is your relationship to stress and pain?" "What are your most pressing concerns about birth and parenting?" "How do you envision your birth?" "Can you show me how you breathe deeply?" "Is there anything in your life you've experienced you would consider traumatic?" All of this information gathering facilitates discussions that help us tailor our approach specifically for our clients.

There have been many times in a woman's labour where the specific knowledge a doula has of her client can really save the day. The more respectful doulas are of the hospital environment they work in, the more trust caregivers can put into the relationship doulas have with their clients, and we can be turned to as tremendously valuable resources. In my years working as a doula, I've come to understand that sometimes it can look to an unsuspecting nurse or doctor that we don't know our doula skills because we're not doing the general things they've learned about to support their patient. For example, sometimes, even though moms "should" be upright a lot through labour and "should" use the bath or shower in active labour to relax and reduce pain, it's important for caregivers not to assume we're ignorant of the application of these comfort measures simply because we're not suggesting them. My way of being a doula is to NOT be over-solicitous, meaning I don't with every contraction ask Mom to get up, change positions, haul out a ball or massage oil, or suggest things. Why? Because after a while it becomes a pain to hear the mosquito buzz of questions in your ear in labour. Sometimes we like to just let our clients BE. It's also important for caregivers to realize that our client has already probably pretty strongly let us know what she needs. Perhaps she's lying on her side because this is her "happy place" and is indeed progressing just great as she is. We can be trusted to ensure she's getting up to pee once in a while and in the process shaking her pelvis around a little. Unless a mom is clearly trying to avoid the hard work of active labour and needs a little energy reversal to shake things up, leaving her to it is often a wise choice.

I've heard doulas have encounters with nurses who thought the doula was acting very strangely, even ignorantly, by fully supporting the mother's insistence upon a seemingly early epidural, and were chided by the nurse who wanted to give them a crash course in comfort techniques. When (with the clients' knowledge and permission of course) the doula took the nurse outside the room and explained the mother was a survivor of sexual abuse and that they had in advance of the labour come up with a plan to demand an epidural when the pain started triggering feelings of emotional instability, the nurses immediately did what was asked, recognizing the value of the doula/client relationship. I remember walking the hall of a hospital and the mom stopped for a contraction, leaned over, and I rubbed her back in the way we had discussed, due to an issue with her sacrum. A nursing student ran up, and said, "Let me," and proudly "showed" me how to do a sacral press because I guess she had learned it was better, even though it was wildly inappropriate for this particular mom. I've had a couple of students chewed out by hospital staff for looking like they weren't doing anything for a mom who had just clearly told them she wanted to rest quietly for a while.

Doulas craft their relationships with their clients painstakingly and lovingly. We find out what coping skills they have to weather the sensations of labour, find out whether or not they prefer fancier breathing techniques, what kind of essential oils they like, and what scares them. If we have had the good fortune to attend their previous births, this relationship becomes MORE powerful. A particular sound or body posture that may be easily missed by others can alert the doula to when this unique mom is about to quickly deliver the baby and ensure the staff is aware and prepared. A midwife I've worked with a few times recently totally put her trust in me to recognize when the silent mom was pushing. She said, "You've been with her before. Come get me when you think she's close if she gets there before the next heart tone check." I sent her sister running for the midwife just before heart tone check time. The husband looked confused and said, "How did you know?" and for me it was just the way she started walking that drew me vividly back to how it was with her previous birth before the baby squirted out.

It's important to remember that as doulas, we don't pay as much attention to times of contractions or numbers of cervical dilation. These are not tools we use to determine where a mother might be in her labour. That is a clinical perspective we leave to the clinicians. Instead, we are in deep observance of Mom's behaviour and subtle shifts in breathing and movement. We talk to the fears that might come up, address areas we knew well in advance she had been concerned about, and use not a whole myriad of techniques and every tool in our doula bag, but the simple things that we know work for THIS lady, because we know her well. We sit quietly, feeling, watching, sensing, sometimes even smelling.

Smelling? Did she just say SMELLING? Yes she did. To end the topic of relationships but to let you know what kind of secret spidey senses many doulas and midwives have, let me leave you on an interesting note: doulas use their sense of smell a lot. It's pretty clear if the mom's just peed herself or if her waters have broken given the ocean water smell of amniotic fluid. Subtle changes in Mom's body smells can let us know she's challenged with something like dehydration or hunger or too much fatigue. I recently told a couple that I smelled their baby coming. They thought this was funny. Baby was out within fifteen minutes or so. Seriously, I have gotten doctors in the room because of that smell (without telling them that). There is sometimes a scent mothers emanate just prior to birthing, a kind of fruity hormonal smell. It smells like fresh baby, ripe apples, and the earth after rain. To me, it's the loveliest scent in the world. Free from any need to worry about clinical things, doulas get to develop more grassroots way to figure out a labour. It may surprise some to know that our magic may run just a little deeper than double hip squeezes and lavender spritz.