Thursday, March 4, 2010
Doulas Behaving Badly
What I want to know is WHO of you doulas out there are doing this?! Because you know what? You've gotta stop. I don't know about you, but I have worked long and hard to get in a position where doctors and nurses trust me. In fact, most of my business is through doctor referral. It is this trust that has led to my good success as a doula. I did not sign on to be a doula who works mainly in hospitals because I am personally a big fan of hospital births in general. I'm an avid home birther. But my purpose and my goal is to ensure women get the best possible care within the system they choose. This is not by control, but by support. I truly feel if all members of the team took time to look into each others' hearts, we would most likely find the same intention...to hold a space, the way we know best, for a safe and happy outcome for the mother, father, and baby. We may have different approaches to this goal, but each member has a valuable role that deserves respect.
I personally think it is extremely bad behaviour on a doula's part to fiddle with equipment in a hospital because you are trying to reduce intervention. This is not advocacy! This is blatant rule breaking, and creates the risk of getting us banned from hospitals altogether. In fact, one of my clients told me that at one of the hospitals I work at less frequently, there is a group of family doctors who refuses to work with patients who have doulas. This breaks my heart, because I know if they could only witness a few good experiences with doulas, they would relax, and see the value of our services for their patients. My best experiences are usually ones in which family doctors are involved, and I think these doctors who have banned doulas are denied of seeing the kinds of births that are common with the presence of a good doula. It only takes a couple of bad egg experiences to put people off eggs.
Why should you not take women off the monitors? After all, they're on there way too long a lot of the time. Because, it is not your role. You can track down the nurse and ask her to please take off the fetal monitor, explaining your client has been on it for the required time. In my experience, once I ask permission, I see the beginnings of trust start to happen. The nurses know I am not out to sabotage their work. Imagine being them for a minute. They are responsible for the monitoring of their patients. It is they who usually decide whether or not a doctor needs to come into the room to check things out based on what's going on with the mother and baby. If a nurse is required to have a mother on the monitor because that is the rule of the hospital, she comes back in and you've undone the whole thing, something happens with the baby, who do you think gets in the most trouble? Probably the nurse.
I'm a pretty experienced doula, and am capable of reading a monitor, getting a general sense of how things are with the baby. But I am not qualified to diagnose this for certain. There are probably a lot of things I DON'T know about reading a fetal monitor, and I'm not going to assume anything. If your client wants to take off her monitor, it is her right to do so whenever she wishes. But not at your request or suggestion. And it is certainly not your right to take her off the monitor for her unless there has been an agreement between you, the client, and the nurse. Ask the nurse. If she doesn't agree for some reason neither you nor your client understand, ask the head nurse. In my experience, when a nurse sees I am playing by the hospital rules, she often gives me permission saying, "okay, take it off, but just buzz me and let me know so I can mark it down." Building this rapport of trust is essential for us to continue our work, so we can demonstrate the kind of birth outcomes that make doctors and nurses stand up and take notice of how important our work is.
Combative doula behaviour is not going to change how the hospital operates. If you go up to a nurse, get in her face, and say, "What do you think you're doing?" every time she has to turn up the Synto (because it's her job), you are not going to teach that nurse a lesson in Synto administration. It's going to make her say, "Screw you and the little weekend workshop you came in on." At the nursing station, they will laugh at you for having the audacity to assume you know the "right" way for them to conduct themselves. Now, perhaps you do. Perhaps you are savvy of evidence based medicine based upon things they have not studied. No matter. Your behaving this way will not ever get your thoughts listened to. No change will be created. In fact, you set it up so there will be a very shaky future for you and your doula sisters to work within.
The environment I work in is accepting and allowing of my doula care, through familiarity, careful diplomacy, and trust. If I were uncomfortable with a way a nurse was administering Synto, I would suggest the mother or her partner to ask, "I really am having stronger contractions now, would it be possible to wait a little before upping the Synto?" (in the hopes that the mother's body will take over, negating the need for more). Most nurses say, "Sure, we can wait a bit if that's what she wants." If they are really adamant about not allowing this and you're not sure whey, you could talk to the resident or doctor, though not in a way to make it seem like you're "telling" on the nurse. They may give you a very valid reason you didn't know about or consider. If everyone says, "no," and you don't get it, the client herself or her partner can certainly speak for themselves. They're not victims here. It is ultimately their battle, not yours. And if they decide to accept this treatment, even if you think it is inappropriate, what do you do? Suck it up. It's not your choice. Yes, it's hard to see things administered when you are very aware of the risks and see them unfolding before your very eyes. But you have to remember: your clients CHOSE hospital birth. By going into this environment they are aware that for the sense of personal safety they're buying by being there, there are some challenges associated with that. Don't assume that because they acquiesce to a procedure you don't like means they feel victimized. Don't assume, "oh, if they had all the information, they wouldn't make this choice." Not true. Your clients are not representatives of your own personal agenda to educate staff members on what you feel is the "stupidity" of their protocols.
You may ask, "what if my client doesn't have the type of personality where they can stand up for themselves?" If you inform them to the best of their ability, giving both sides of the coin, your client can tell you what she wants when you have a private moment, and you can communicate it, letting the staff know you are stating your client's wishes, not yours. I'm not personally a fan of doing this, as I think even if women can't speak because of the labour, their partners can. But sometimes you're with a very vulnerable woman who is alone, and you make exceptions. If, however, she can't stand up for herself even with your help because she's afraid of creating conflict, making choices based on not rocking the boat instead of on what she needs, you have to wonder at what point you are at the line between empowering and enabling. Where does your role of advocacy end and your journey of owning the birth for your client begin? Stand back and re-examine your intention.
If you can't stand the heat, get out of the kitchen. If you loathe attending hospital births, stop. If you cannot abide the procedures and the way women are sometimes treated there, fair enough. Not everyone can stomach it. If you feel like you have to weep every time a woman gets an unwarranted vaginal exam, even if she doesn't seem to mind, you are in the wrong profession. Maybe midwifery is more your calling, so you can provide consistently compassionate clinical care. You know what? I don't like MOST of the ways birth is dealt with in the hospital. And that is precisely WHY I'm there. I know, through experience, that gently and lovingly going about my work, being present for each experience, finding the best in people, making friends, respecting ideas, and working together is how the change is made. I have to digest an awful lot of crap and witness some yucky things in order to do so, but I can tell you it is working. The head of OB at one of the hospitals my colleague Rivka and I work was at a meeting some nurses and doctors had invited us to. She acknowledged and honoured our work there, recognizing the importance of our statistics, and is interested in using us as resources to help lower the rate of some of the interventions. The doctors and nurses had to qualify, "Lesley and Rivka are GOOD doulas," implying there are problems with doulas out there who are on political rampages, in violation of active but non-violent communication.
Doulas, you have TREMENDOUS power to bridge the gap between holistic and medical maternity care. We can help warm up a frosty nurse with friendliness. We can have our clients ask questions about their care which lead to their choices being honoured. We can encourage and praise a new doctor for catching a baby in an "alternative" position so he feels more confident about it for the next lady who comes along. We can show them that most women can give birth without pain management if they choose and circumstances favour this choice (if you set up a lot of tension and conflict, this will be less likely...it may not after all be the "system" to be "blamed" for the woman's epidural..it might be you). I have had lots of doctors and nurses ask me about the non-pharmaceutical ways I help to ease back pain in labour. They are interested. We can buffer the environment, and support our client strongly when things go out of every one's control. These are small but powerful ways we work, creating momentum. But we need a mellow environment for that work to grow.
Simply put, women are not all gonna be running off and having home births just because we embrace it to be a safe, wonderful option for most families. The vast majority of births are going to be in a hospital, like it or not. Is our mission to be "right" and go about snottily proving it to every nurse who ups Synto through an IV, or is it to lovingly welcome in a baby to a mother who feels as empowered, respected, and loved as we could make her feel? If she has a crappy birth experience in spite of all your good work because the people at the hospital were nasty that day, well, that might make her choose a different option the next time. And if she has a wonderful experience, is this not MARVELLOUS enough?
So, all you doulas behaving badly out there, please understand you are hurting the cause. You may justify yourselves all you want by making snide remarks about brown nose diplomacy. I would rather wipe off the occasional stain than have my spotless snout shut out entirely and responsible for leaving vulnerable women unbuffered in that system. Because that is effectively what you are doing. Instead of healing this birth culture through your angry, righteous approach, you are going to get doulas, the very ones who hold the power to heal it, barred from hospitals entirely. When that happens, those hospital birthing women will not have access to the care they need from us, thus limiting their choices and potential for amazing experiences within that harsh environment even further.
A woman's birth is her own journey. It unfolds for her, provides lessons, transforms her, and gives her a baby. There is not a lot of control over that. Sometimes you have to sit back and watch things you don't agree with go on. Midwives and doctors do this too. If you think a birth full of interventions is necessarily a reflection of how good or bad you are as a doula, and this is one of the reasons you are so viciously opposing them, you are working from your Ego. Let it go, Sister, and focus on the bigger picture. We need you.