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.

Thursday, March 8, 2012

Happy Women's Day!

I spent a wonderful day honouring Women's Day by doing the work I love to do.

At noon I met with a pregnant couple and had the pleasure of being accompanied by one of my lovely apprentices. One of my tasks in being a doula, I feel, is to connect women with the internal resources they have to bring to their birth/parenting experiences. It was wonderful to learn how how this lady had done some serious work in her life to actively heal issues and create healthy boundaries. This type of emotional inventory and process work does wonders in releasing energy bound up by our past, thus creating more available resources with which to birth. I was so glad to see what a natural my apprentice was, taking the opportunity to really honour this woman's work, connecting her to the value of what she had done for herself, and her future child. I could also feel a strong desire from the woman's partner to be a great birth supporter. We nurtured that desire, emphasizing how valuable it is to have a partner lovingly committed to doing his best to help his child into the world.

There are so many ways in which our culture builds up the image of men being real dufuses during labour, and it's simply not fair. Sure, some couples prefer, for whatever reason, Partner be less hands on, and that is fine if both parties are in agreement and honour each others' expectations. But from my personal experience, I find when a man is really invested in being there for his woman and child, willing to embrace the experience as her expression of power, allowing himself be vulnerable, open, and a rock all at the same time, the experience is all the more special. It is an amazing bonding opportunity to have together, starting new parenthood off on powerful footing as a dedicated team.

Next appointment was with another lovely apprentice's company. We did a first prenatal meeting with a couple we had not met in person before, so we were both on the same footing. I just love getting to know folks and getting a sense of what may help them have the best experience possible. I learned that this couple have great resources in terms of being able to relax into and cope with stress. What I felt was most called for in this meeting was to create excitement about the normal process of birth. We are enculturated to tell each other horror stories, projecting our fear onto innocent pregnant ladies who become too scared to even dream of anything normal the more they are infused with that fear. So to neutralize it, I tell good stories, and recommend books not full of alarmist advice, but wonderful, triumphant stories. It doesn't dumb women down to have them feel positive about their upcoming birth experiences. Feeling confident doesn't put rose coloured glasses on them. This seems to be what we want women to believe: if they feel positively about birth, they'll be all the more hurt if things don't go as expected. So we seem to take it upon ourselves to save them from what we assume will be their feelings of failure or disappointment by "reminding" them of harsh realities with all the tales of birthing woe we can muster. Telling good stories and discussing birth as a wonderful thing reduces fear, fear itself being responsible for many of the challenges in labour and birth; not on an airy fairy plane, but a real, physiological, hormonal level. Confidence and hope are resources, not foolish fantasies of the uninitiated and ignorant, as we tend to imply with our our obsession with telling stories filled with awful drama to pregnant ladies. So much can be healed simply by changing the tune of our stories. Our telling of the good stories is narrative medicine at its finest.

My third meeting was with a new mother and father. Again, I had the pleasure of being accompanied, this time by a seasoned MotherWit apprentice. We've gotten to work together a couple of times, and I just love her strong, loving presence. She exudes safety and capability. Our couple's baby had had some feeding problems, but it was great to see this greedy little munchkin gobbling back milk like there was no tomorrow, getting fat and pooping up a storm. Mama was entirely exhausted, though, and while putting on a brave face, was clearly feeling quite challenged by the demands of growth spurt nursing, fatigue, and a baby who won't sleep without being in constant contact with a parent. And Dad, well, he's just anchoring it all, doing all the countless unseen beautiful things new daddies do to support their partners and babies as best they know how, all the while feeling as overwhelmed as she.

It does something to my heart to see grownup professionals, people who have lived out in the world gaining tons of life experience, masters at what they do, to be reduced to rank amateurs when they hold their baby in their arms the first time. I am filled with the most maternal feelings, not for the newborn baby, but for the newborn parents. It doesn't matter who we are or how many degrees we have or places we've traveled. When we have our own first babies, we are brand new and experience the joys, triumphs, discouragement, and frustration of those trying to master something we've never done before. But we're doing it with the hearts of those invested like never before, feeling love and responsibility so great, it renders us speechless in the spaces we have between diaper changes to think. We also try to manage all the endless tasks of new baby care running sometimes on empty. Not living tribally anymore, it is difficult to get the rest, food, and support we need to do this sacred work with as many resources as we could have if we were cared for just a little more. A doula's visit can cut to the chase of what's needed in terms of resources,while acknowledging all the positive things going on (but not in an annoying, "count your blessings" preachy kind of way).

As is typical on postpartum visits, we saw tired parents who needed more sleep, and tips on how to get Baby (or at least to try) to sleep. Baby was not at all happy with lying on the back sleeping by herself. Not that it caused intense distress, but she just woke up every time she was put down and cried for company. It's easy to say, "Well, just hold her all the time then," when we are avid about attachment parenting ourselves, but for those not used to such intense physical contact all the time, that advice can exacerbate feelings of helplessness. We gently talk about how many babies do indeed prefer being held most of the time as they're getting used to life outside of the cozy womb, but we also like to give some tools parents can try so they can decide for themselves how to sooth their fussy baby. We showed some swaddling tips (keeping in mind, this Baby nurses skin to skin and is gaining like a champ) and Baby holds to reduce gas in the tummy.

The parental tears came flowing at the admittance of overwhelm, as well as the guilt that always seems to come up with feeling overwhelmed. Though personally, I think feeling overwhelmed by having a baby is pretty appropriate. It's not easy! Sometimes when I show someone a way to hold their baby that calms them and then lie them down and they stay asleep, it makes them feel like they've been missing something crucial and reinforces feelings of their imagined inadequacy. I am sensitive to this, and have to remind them that I have twenty years and four babies worth of mothering experience (not to mention having showed colic holds and laying-down techniques to countless hundreds of parents), but at one time I was in the exact same position with the world's most colicky baby. By a couple months in though, I was an expert, and I assured them they will be too. There's nothing like learning in the field. I got great advice from my mother, my grandmother, my midwife, my doula, and La Leche League friends to help me along the way. Parenting is part instinct, but part learned as well. We learn how to be skilled parents not just from books and intuition, but by being lovingly taught skills by other parents or people with a lot of experience with babies. How we "experts" relay these skills is very important, as there's a fine balance between building resources and giving unsolicited advice to stoke our own egos. So it's always so important to let new parents know that we all have felt like overwhelmed newbies at some point, that their feelings are absolutely normal, and that in fact, I'm still overwhelmed a lot because I've never had a teenage boy before, or a daughter about to leave the nest. I have to consult with my friends who have grown kids all the time to learn ways to cope with new challenges. We're always newbies at any given stage of parenting. But nobody is quite as sensitive, tired, and hormonal as the parent of a newborn, so our resource building must be gentle and empowering, filled with reassurance that they are doing beautifully. They need to know that just their desire to try, their willingness to show up for those late night feeds and massive, up the back poop-alanches, their heartfelt desire to be good for this teeny little scrap of human, makes them BRILLIANT.

I left these parents with a few ideas on how to get more sleep, dates of our MotherWit Mom's Group to reduce feelings of isolation and have a space where mother to mother support can be exchanged by those in the same boat, and the number of an osteopath I trust to tend to some of the issues of tension and difficulty in settling this wee one has. It is often as simple as a little cranial/sacral alignment to aid digestion and relaxation in a newborn. We left them with big hugs and promises that it would get easier and that they would soon feel more mastery over their situation.

It was a great day, and now I get to hang out with my younger teen daughter and her friend to wrap up a lovely Women's Day. Blessings to all of you precious women out there.