Birthing Beautiful Ideas

Depending on your perspective, the dust has either just begun to settle or just begun to get kicked up on the Kingsdale Gynecologic Associates’ doula ban and universal birth plan.

On the one hand, the dust is really swirling in the Columbus, Ohio media.  Two local news programs aired evening news segments on the ban, and the Columbus Dispatch ran a front page story on the issue just last week.  (Many, many thanks are owed to Columbus-area doula Catie Mehl for representing local doulas in all three of these stories!)

On the other hand, the dust in my own mind (a place that can get pretty darn dusty) is finally settling.  By that, I mean that I’ve finally been able to look at the doula ban and birth plan with less snark and shouting-from-the-rooftops and more reasoned, tempered outrage.  And because of this, I’m ready to address people’s questions about why Kingsdale’s recent decisions warrant any sort of outrage whatsoever.

And I understand–I really, truly do–why the source of this outrage isn’t immediately apparent to everyone who comes across this story.

For one, I understand why some people assert that Kingsdale has the right to practice as they choose.  (Though as I will explain later, this doesn’t necessarily mean that everything that they practice is respectful of women’s autonomy, devoid of any condescension or paternalism, or even evidence-based!)

What’s more, as a few people astutely pointed out in their comments, both documents (i.e. the doula ban letter and the Kingsdale birth plan) are worded so innocuously and even reassuringly that it might be difficult for many parents–regardless of their education levels–to note the glaring problems contained therein.

But the problems are there, and they are glaring to my eyes.

Here are the issues as I see them, in no particular order:

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Both Kingsdale documents are embarrassingly paternalistic.

Dr. Kimberly Shepherd, one of the OB/GYNs at Kingsdale, commented in the Columbus Dispatch that the accusations of paternalism and closed-mindedness were “hurtful.”

I, for one, did not intend to hurt anyone’s feelings by referring to the doula ban and birth plan as paternalistic, nor would I disagree that Dr. Shepherd and most (if not all) of her colleagues are nice people who do not deserve to have their feelings hurt.

Nonetheless, this does not change the fact that the documents are paternalistic.

Consider the following definition of paternalism from The Standford Encyclopedia of Philosophy:

Paternalism is the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm.

In a nutshell, then, paternalism describes when one interferes with another’s (or others’) freedom “for their own good” (or at least for what one thinks is another’s own good).

On a theoretical level, some people will agree that despite the value that “we” place on a person’s freedom to make choices about what they believe and how they act in the world, paternalism might be justified either when people lack the cognitive or emotional capacity to promote their well-being or when people act in ways that undermine their or others’ well-being.  Thus, the state mandates safety belt laws, and parents stop their kids from exercising their freedom to flush their brother’s puzzle down the toilet, and most people don’t raise a stink about it.  Except for the kid who really, really wanted to flush the puzzle down the toilet–you know, that kid who may or may not be related to me.

In any case, paternalism isn’t always so benign.  Consider this definition from Wikipedia (yes, I know):

The term may be used derogatorily to characterize attitudes or political systems that are thought to deprive individuals of freedom and responsibility, only nominally serving their interests, while in fact pursuing another agenda which is directly against the interests of the individuals.

I’ll stop with all of the highfalutin thinking (and the Wikipedia, oh my!) just to say that the Kingsdale doula ban and birth plan seem to fall somewhere between the more benign (though not-without-controversy) paternalism and the derogatory paternalism.

To explain, I’m sure that the Kingsdale physicians’  attempts to limit a woman’s choice to have a doula, or to forego an IV, or to eat and drink during labor, or to use intermittent fetal monitoring in low-risk labors are all decisions with the goal of “protecting women from harm.”   Nevertheless, these decisions are also, even if unwittingly, depriving the Kingsdale patients of freedom and responsibility and, in some cases, acting in ways that might not benefit women’s interests (which I will explain in more detail soon).

This is troubling.  It is highly troubling.  And it deserves a (carefully chosen) derogatory descriptor, regardless of whether that descriptor hurts people’s feelings.

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In some cases, the birth plan might offer false reassurance to the women under the care of Kingsdale Gynecologic Associates.

One of the first things that bothered me in the birth plan was the claim that Kingsdale’s universal birth plan would help to “minimize the work ahead” of the busy parents in their practice.

On one level, I get that.  I get that expectant parents are busy.  I’ve been an expectant parent–twice–and I was busy the first time and even busier the second time.  And I appreciate that Kingsdale wants to help minimize the work in lots of busy parents’ lives.

But they don’t have to minimize birth options in order to do so.

This doesn’t mean, of course, that I expect every pregnant woman and her partner to scour every single reputable book on pregnancy and birth, or to prepare for labor in the way one prepares for a dissertation.  But I do think that families should devote at least as much time researching labor and birth as they would to researching the new digital camera that they want to buy, or picking out their baby’s stroller/car seat combo, or whatever it is to which they devote their research energies.  Moreover, I think that families should be able to create birth preference lists–lists that don’t exactly map out or plan their births, but lists that help to explain their reasonable and researched wishes to their care providers.

So in an ideal world, if Kingsdale wanted to “minimize the work ahead,” they could make a list with the pros and cons or risks and benefits or alternatives and trade-offs of every single birth intervention they include on their list and then discuss these options with their patients in order to determine their patients’ birth preferences–preferences that might need to change based on the course of pregnancy and labor, but preferences that should be honored, when possible, based on a respect for women’s autonomy and informed consent.

(Okay, I think I’m veering off into dream-world here.)

One of the other (among many) false assurances I found in the Kingsdale birth plan was their claim that “the labor and delivery nurses and doctors together act as ‘doulas’ in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.”

I do not doubt that the nurses and doctors who support Kingsdale patients suggest positioning options, discuss options for pain control, and make recommendations regarding pushing techniques.  But I highly doubt that they offer continuous physical, emotional, and informational support during labor.  I doubt that they even have the time to function as a doula during their extraordinarily busy shifts!

And this is not a bad thing–it isn’t their job to be a doula.  And it isn’t a doula’s job to act as a nurse or midwife or doctor!  (For what it’s worth, I will agree with the Kingsdale doctors that any doula who tries to take on one of these roles is acting outside of her scope and should face some sort of reprimand, such as having a grievance filed against her with her certifying agency.)

But a doula does much more than tell a woman how to position herself and how to control her pain–we focus more on helping women to cope with pain, for what it’s worth–and I wish that the Kingsdale physicians would take this into account when they tell their patients that they can act as doulas.

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The doula ban and parts of the birth plan ignore and/or fail to mention evidence-based medicine and severely undermine a woman’s right to informed consent.

This one is the biggie.

It’s the problem that made me nearly jump out of my skin when I read the Kingsdale birth plan.

And it’s the problem that might go unnoticed to many people not well-versed in the birth research–and this would have included myself just over two years ago!

“Evidence based-medicine” refers to medical practices that are based on the highest-quality available research.  And sadly, many of the decisions included in the Kingsdale birth plan dismiss, ignore, or even contradict the most current evidence-based medicine.

Moreover, “informed consent” refers to a process of communication, full disclosure, and decision-making in which patients can not only learn the nature, purpose, and various risks and benefits of a recommended medication or procedure but also make a personal medical decision based on the information that they receive.  And sadly, the Kingsdale birth plan limits a woman’s ability to make a fully informed choice about the maternity care that she receives.

I could go on and on about how the Kingsdale documents effectively undermine women’s autonomy, the right to informed consent, and possibly women’s health in the most sinister and willfully ignorant ways.

But instead of allowing this post to balloon even further into a “Birthing Beautiful Ideas Rant-o-rama,” I’ll just let the evidence-based medicine speak for itself–the evidence that can help women to make better-informed decisions about their births.  And the evidence I cite below comes from the Cochrane Reviews database, a database that includes “all the existing primary research on a topic that meets certain criteria” which is then “searched for and collated, and then assessed using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment.”

In other words, this is typically very high quality (and regularly updated) evidence.

And it’s the sort of stuff we want our doctors paying attention to.*

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On restricting nourishment (or oral fluid and food intake) during labor:

“In some cultures, food and drinks are consumed during labour for nourishment and comfort to help meet the demands of labour. However, in many birth settings, oral intake is restricted in response to work by Mendelson in the 1940s. Mendelson reported that during general anaesthesia, there was an increased risk of the stomach contents entering the lungs. The acid nature of the stomach liquid and the presence of food particles were particularly dangerous, and potentially could lead to severe lung disease or death. Since the 1940s, obstetrical anaesthesia has changed considerably, with better general anaesthetic techniques and a greater use of regional anaesthesia. These advances, and the reports by women that they found the restrictions unpleasant, have led to research looking at these restrictions.  In addition, poor nutritional balance may be associated with longer and more painful labours, and fasting does not guarantee an empty stomach or less acidity.  This review looked at any restriction of fluids and food in labour compared with women able to eat and drink. The review identified five studies involving 3130 women. Most studies had looked at specific foods being recommended, though one study let women to choose what they wished to eat and drink.  The review identified no benefits or harms of restricting foods and fluids during labour in women at low risk of needing anaesthesia. There were no studies identified on women at increased risk of needing anaesthesia. None of the studies looked at women’s views of restricting fluids and foods during labour. Thus, given these findings, women should be free to eat and drink in labour, or not, as they wish.”

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On epidural analgesia:

“Epidurals are widely used for pain relief in labour. There are various types, but all involve an injection into the lower back. The review of trials showed that epidurals relieve pain better than other types of pain medication, but they can lead to more use of instruments to assist with the birth. There was no difference in caesarean delivery rates, long-term backache, or effects on the baby soon after birth.  However, women who used epidurals were more likely to have a longer second stage of labour, need their labour contractions stimulated, experience very low blood pressure, be unable to move for a period of time after the birth, have problems passing urine, and suffer fever. Further research on reducing the adverse outcomes with epidurals would be helpful.”

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On continuous electronic fetal monitoring during labor:

“This review compared continuous CTG monitoring with intermittent auscultation (listening). It found 12 trials involving over 37,000 women. Most studies were not of high quality and the review is dominated by one large, well-conducted trial of almost 13,000 women who received care from one person throughout labour in a hospital where the membranes have either ruptured spontaneously or were artificial ruptured as early as possible and oxytocin stimulation of contractions was used in about a quarter of the women. There was no difference in the number of babies who died during or shortly after labour (about 1 in 300). Fits (neonatal seizures) in babies were rare (about 1 in 500 births), but they occurred significantly less often when continuous CTG was used to monitor fetal heart rate. There was no difference in the incidence of cerebral palsy, although other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with a significant increase in caesarean section and instrumental vaginal births. Both procedures are known to carry the risks associated with a surgical procedure although the specific adverse outcomes have not been assessed in the included studies.”

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On continuous labor support (from people who may or may not be doulas):

“Women who received continuous labour support were more likely to give birth ‘spontaneously’, i.e. give birth with neither caesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. In general, labour support appeared to be more effective when it was provided by women who were not part of the hospital staff. It also appeared to be more effective when commenced early in labour. No adverse effects were identified.”

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On episiotomy:

“Restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth. Overall, women experienced more anterior perineal damage with restrictive episiotomy.”

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There are risks.  There are benefits.  There are pros and cons.  There are trade-offs.  There are even mentioned (and unmentioned) alternatives to the above-mentioned interventions and procedures.

And this is only some of the information–only a fraction of the research on obstetrical practices–that women should be able to learn before they decide their birth preferences and before they have these preferences chosen for them.

So why not allow women to seek out this information themselves?

Why not condense it or collate this information for them to make their decision-making process easier?

Why choose for all women’s births, even if they are healthy, low-risk moms?

Why not allow women to choose and decide and think for themselves?

(And now I’m officially (and finally) done blogging about the Kingsdale Gynecologic Associates’ doula ban and birth plan.)

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*Worth noting is that the evidence does not necessarily have to come directly from a Cochrane Review in order for it to be considered the sort of high-quality research needed to constitute “evidence-based medicine.”

This morning, I will be sending out my doula certification packet to DONA International.  This moment has been a long time coming for me.  (Long story short, I moved to a new state less than two weeks after I attended my third birth, and this was over a year ago.  My own certification journey became a bit…delayed after the move.)  As part of my certification packet, I needed to write a 500-1000 word essay describing the purpose and value of doula support.  I am pretty pleased with my essay, and I’ve copied it here as a way to celebrate this moment.  Enjoy!  And wish me luck!

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In recent years, people have become more familiar with the concept of a “doula.”  They might know that doulas are women (and, though rarely, men) who offer continuous emotional, physical, and informational support to a laboring woman.  They might even know of some doulas who practice in their area.  What’s more, they might even have misconceptions about doulas: for instance, that doulas are only for women who want un-medicated births, or who want homebirths, or who are not planning a cesarean section.  But beyond these basic understandings and/or misconceptions, what many people do not yet know are the benefits of doula support—the purpose and value of having continuous support during  labor.

The benefits of doula support are well-documented.  According to a Cochrane Review of the research on continuous support during labor,[i] doula support has been shown to increase a woman’s likelihood of a spontaneous vaginal birth (i.e. a birth without forceps or vacuum extraction or cesarean section).  What’s more, women who have continuous support during labor—such as the support of a doula—are less likely to use pain medication, more likely to feel satisfied with their birth experience, and may have labors that are slightly shorter than the labors of those who do not receive continuous labor support.

But these measureable benefits do not exhaust all of the possible benefits that doula support can confer to a woman, her infant(s), and her family.

For it’s difficult to measure the exact amount of reassurance given to a woman when a doula holds her hand and reminds her that “she is doing it!” just as she doubts her ability to cope with the power of her labor.

It’s difficult to measure the joy of a father who tells his doula that “this was the first time that I didn’t feel like I was watching a medical event as my wife gave birth—this time, I felt like I was helping to bring our baby into the world.”

It’s difficult to measure the precise level of relief that the double-hip squeeze gives to a woman working through back labor or the specific level of empowerment that a woman feels when her doula has helped her to research her birth options or the particular type of love that a couple feels when their doula helps to maintain a compassionate and caring birthing atmosphere, no matter what unexpected situations arise.

But these benefits are real, intangible and resistant to measurement as they may be.

And so if I could teach people about the benefits of doula support, I would describe to them all of these benefits and more.  I would let them know of the documented and well-researched benefits of continuous support during labor—the increased likelihood of spontaneous vaginal birth, the decreased likelihood of pain medication, and so on.  But I would also give them at least a glimpse into those intangible benefits too—the ones that represent the love and kindness and humanity and joy that a doula can bring to a woman’s labor.

My in-laws (and my entire family, for that matter) have been a huge support to me during my journey as a doula and birth and breastfeeding advocate.

In fact, they were with me during one of the key moments that ignited my birth advocacy.  And on that night when I vowed, at 36 weeks pregnant, to leave my then-current OB/GYN in search of a more VBAC-friendly care provider, they raised their glasses to me and toasted “to me, our family, and to VBACs!”

Yes, they are fabulous people.  I’m a lucky daughter-in-law.

And I guess it’s no surprise that, given their support and the ways in which my birth-related passions often weave their ways into my conversations with others, my in-laws have become mini-birth advocates in their own right.

Just a couple nights ago, my father-in-law was telling us about how the woman who cuts his hair is pregnant.  During their haircut chit-chat, he mentioned something about my work as a doula.

Because his stylist had never heard of a doula before, my father-in-law proceeded to tell her a bit about doula support: what we do, what our purpose is, etc.  And then he described, somewhat nonchalantly, the fact that she has “all sorts of options that she can choose for her birth!”

(What wonderfully empowering language, right?!)

And she was, in my father-in-law’s words, “completely mystified.”  She was shocked that she could bring additional labor support for her child’s birth.  She was amazed that she had a multitude of comfort measure options.  She was astounded that she had options for her baby’s birth.

Now I don’t know if the hair-stylist at Upscale Male in Naperville, IL went straight home and Googled “doula support” later that evening.  I don’t know if she looked up comfort measures for labor.  I don’t know if she found out her care provider’s cesarean section rate or if she’s even interested in finding out that information.  I don’t even know if she’s going to take a childbirth education class.

But she at least knows now that she has options.

That’s a pretty big deal.  It’s a big deal because it’s something that she didn’t know before she spoke with my father-in-law.  And it’s a big deal because so many women wish we did know this before we birthed our babies.

And on behalf of all birthing women, I’ve got to thank my father-in-law for that.

grandpa and and doula-supporter extraordinaire

First thing’s first: the lucky winner (chosen at random on random.org) of a copy of Penny Simkin’s remarkable book, The Birth Partner, is…Jillian, who commented on Facebook that, “Doulas are for women who are trained in the medical field, especially those that provide care for others during the time surrounding pregnancy and infancy. Sometimes knowing too much, especially about potential complications, can lead to a lot of anxiety. A doula encourages the quieting of mental noise through reassurance and empowerment, so relaxation and and trusting in instinctual body urges can take over.”  Congratulations, Jillian!

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I have been so moved and inspired by all of the entries to my giveaway contest for International Doula Month.

When I first came up with the idea for this contest, I thought that people would offer up simple statements in their entries: that doulas are for moms of singletons, or moms of multiples, or teen moms, or moms over 40, or women who are birthing in a hospital, or women who are birthing at home, or women birthing with midwives, or women birthing with obstetricians, and so on.

All of these statements are just as important, just as crucial to the public understanding of doula support, as any of the statements that you all sent in to me.

But the ones that you did send were especially thoughtful.

So thank you to all of those who entered the contest.  For those of you who didn’t win, I hope that the statements below are enough of a gift back to you, whether you are a mother, a birth professional, or even simply a friend of birthing women.

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Doulas are for women who want to have an empowering childbirth experience!

Whether through information, support, encouragement, processing, and so forth, a doula helps a woman realize that she has more strength than she ever knew!

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Doulas are for women who miss their mothers.

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For many women and their partners, the cost of doula support (which can range anywhere from a couple hundred to a couple thousand dollars) can seem quite prohibitive.

This is often the case even if they value the commitment and work that a doula offers to each of her clients and even if they already know about the invaluable benefits that doula support confers to laboring women.

But even with limited funds, it can be possible for almost any woman who wants a doula to hire one.  Here’s how.

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Consider hiring a certifying doula.

Doulas who are in the process of certifying will often offer reduced fees or even free services to their clients.  Finding a certifying doula can be a wonderful route to take if you are seeking out more affordable doula support!

Some women have success finding certifying doulas on Craigslist or other local community boards where new (and more experienced doulas) will advertise their services.

As with any other doula search, you can also check Doula Match to find new doulas offering reduced rates in your area.  In addition, you can send an email to doulareferrals@dona.org to request a list of uncertified DONA International member doulas in your area.

For what it’s worth, don’t be worried that you will automatically receive “inferior” support from a new doula.  Finding the right doula is more about finding the person who you feel most comfortable with than finding the person who has attended hundreds of births.  And a new doula might end up being just the perfect doula for you!

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Find a local doula who will barter for part (or all) of her fee.

Do you or your partner make things?  Fix things?  Sell things?

Are you handy with a paintbrush, a wrench, or a sewing machine?

Do you clean houses, cook meals, or offer massage therapy?

Then you might be able to find a doula who is willing to barter with you in exchange for her services!  And especially if your service is pregnancy, parenting, or breastfeeding-relevant, you might even develop a good business relationship in the process.

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Simply ask for a payment plan, a reduced fee, or sliding scale based on your income.

Many doulas will offer a reduced fee to women or families who cannot afford the regular fee.  Many are also willing to set up a contractual payment plan so that you can spread the payments out over time rather than paying the doula fee in one or two large installments.  It never hurts to ask one or more of your local doulas if they are willing to offer these payment options to you!

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Seek out a local or national volunteer doula organization.

Radical Doula created a fabulous list of volunteer doula organizations throughout the United States and Canada.  (Make sure to check out the comments section for further contributions to this list!)

Thus far, the only national program on the list is Operation Special Delivery, an organization that provides volunteer doulas to women whose partners who will be deployed at the time of birth or who have been severely injured or lost their lives during the current wars in the U.S.  I’m not aware of any others, but if you know of one (or more), please let me know!

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So don’t think that a doula isn’t for you just because you don’t think that you can afford one.  With just the right research and just the right questions, you might be able to find low-cost or even free labor support from a doula near you!

This post is a part of my “Doulas are for All Types of Women” series honoring International Doula Month.  I’m also giving away a copy of The Birth Partner by Penny Simkin for International Doula Month.  Please see my original post in this series to find out how you can win!

It can sometimes be a mental hurdle for people to get past the idea that doulas aren’t only for women who choose a “natural” or drug-free birth.

It can be even more of a mental hurdle for people to get past the idea that doula support is only for women who are planning vaginal births!

But in reality, doula support can be quite valuable for women and families who are planning a cesarean section for the upcoming birth of their child (or children).  Here’s how.

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A doula can help you to create a cesarean birth plan.

Yes, you can create a birth plan or birth preference list for a planned cesarean section!

And a doula can help you to determine what preferences you would like to include on your list.  What’s more, she might even inform you of some options that you didn’t even know that you had!

For instance, would you like to specify that your urinary catheter to be inserted after the spinal epidural is placed?

Would you like someone to explain the surgery to you as it happens?

Would you like to have music playing during the c-section?

If your baby is healthy, would you like to be able to hold him or her while you are being moved to the recovery room (with assistance, if needed)?

Do you have any postpartum preferences, such as those related to breastfeeding or vaccines?

These items and more can all be included in a cesarean section birth plan or preference list.

(If you’d like to read more about cesarean birth plans, Morgan at Adventures in Diapering and Beyond created this example of a C-section Birth Plan for her readers.  She has had four c-sections herself and has some great experiential wisdom to offer here.)

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A doula can take the time to discuss your feelings about the c-section and offer any tips or advice on recovery well before the big day arrives.

Especially if this is your first cesarean section, you might have some fears or concerns about your upcoming surgery.  Well before your baby is born, a doula can help you practice relaxation techniques (such as breathing exercises or visualization) that you can use during the epidural or spinal placement, throughout the surgery, and during your recovery period.

Where appropriate, a doula can even help you to devise ways to alleviate your fears or concerns in your birth preferences list.  For instance, some women who become nauseous at the very thought of surgery might request that no one describe the cesarean section as it happens–or at least that any conversation between the medical staff be as least graphic as possible.

A doula can also help you to plan ahead to ensure that you to have your best recovery possible. Whether it’s demonstrating the breastfeeding positions (such as the football hold) that seem to be most comfortable to women recovering from a c-section, or recommending that you bring a breastfeeding pillow (such as a Boppy or My Brest Friend) to wrap around your abdomen even when you’re not nursing, or suggesting that you ask friends to offer to perform light housekeeping in lieu of bringing baby gifts, a doula might be able to offer you just the sorts of tips and advice that will make your initial recovery from major abdominal surgery as smooth as possible.

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A doula can support your husband, partner, or other support person while you are being prepped for surgery.

In many cases, a dad and/or a doula is not permitted to accompany a woman into the operating room during the initial preparation for surgery (including the spinal or epidural placement).

And in many cases, dads or partners are extremely nervous during this waiting period!

A doula can help a woman’s support person to remain calm while s/he is waiting for the “okay” to enter the operating room.  She can help to describe what will likely occur during the surgery, she can remind him or her of any “responsibilities” that s/he might have (such as taking pictures after the baby is born), or she can even just offer the general emotional support and encouragement that the dad or partner might need at that very moment.

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If your anesthesiologist and OB/GYN allow it, your doula can remain by your side during the surgery.

In some cases, care providers will allow a second support person (such as a doula) to accompany a couple during a cesarean section.

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This can be particularly helpful after the baby is born.  Oftentimes, the baby must be monitored in an area of the operating room that is relatively far away from the mother.  Sometimes, this monitoring is even performed in a separate nursery.  With a doula by your side, your husband or partner can go to be near the baby without having to worry about leaving you alone.

In addition, it can be particularly helpful for a woman to have a doula by her side while her uterus is being repaired.  To the surprise of many women, this is the longest part of a c-section, ranging anywhere from twenty minutes to a couple of hours, often depending on how many previous cesareans a woman has undergone.  Having continuous emotional support from a doula at this time can be exceedingly important for some women.

If you would like your doula present during your cesarean section, especially if you plan for your husband or partner to accompany you as well, please make sure to discuss this option with your care provider and with the hospital staff.  Often, the policies on this issue vary from doctor to doctor.

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Your doula can offer physical and emotional support in the recovery room.

The  initial recovery period can be quite stressful for a new mom.  Her spinal or epidural is wearing off, she may feel groggy from that or other pain medication she is now receiving, and she has very limited mobility.  And did I mention that she also has a new baby?!

A doula can help both a mom and her partner to have as peaceful a recovery as possible.  She can guide a mom through various physical comfort measures (such as guided breathing or visualization) if the mom is experiencing a lot of pain.  She can help with positioning, both for breastfeeding and for simply holding the baby.  She can take pictures, she can wipe away tears, and she can even set up an appointment to join you at the hospital later that day or the next to help you as you regain your mobility and begin the sometimes arduous task of walking.

And when desired, she can recommend local or national groups (such as ICAN) that can offer you peer-to-peer support in your physical and emotional recovery.

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So while doula support during a planned cesarean might look much different from doula support during a planned vaginal birth, it is still the same in spirit.  In other words, a doula can still offer physical, emotional, and informational support to you before, during, and after your cesarean birth.

And you might even be surprised find how much this support enhances your experience and eases your recovery!

This post is a part of my “Doulas are for All Types of Women” series honoring International Doula Month.  I’m also giving away a copy of The Birth Partner by Penny Simkin for International Doula Month.  Please see my original post in this series to find out how you can win!

“My husband/partner is going to be right with me during my labor.  S/he even took the whole childbirth class with me!  Why would we ever want or need a doula?!”

I’ve heard and seen many pregnant women ask themselves this very question.  Most of the time (though certainly not all), I think that this question rests on a few misconceptions about childbirth, doula support, the expectations we have of “inexperienced” birth support people, and the realities of birthing in a hospital.

In other words, even if you think that your own personal birth partner negates the need for doula support during your baby’s birth, you might be surprised about just how much you might want a doula when you’re actually in labor!

This isn’t to say that you might find that when it comes to labor, you personally don’t really need or want a doula.

Maybe your partner is a “natural” when it comes to birth support.  Maybe your care provider is one who has the time to stay with you throughout your labor and support you and your partner as you bring your child into the world.  Maybe you are birthing at a place where the staff also has the time to offer you continuous support throughout your labor.  Or maybe you’ve chosen to birth unassisted!

But before you dismiss doula support entirely, please consider the following reasons why you still might want–or even need–a doula when the big day arrives–even if you have a wonderfully supportive partner right by your side.

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Doulas don’t just support the laboring women–they also support their partners.

Without a doubt, the person working the hardest on any “birthing” day is the woman giving birth.  (And before anyone gets the silly idea that the surgeon is the person “working the hardest” during a c-section, let me just remind you that s/he probably doesn’t have to recover from major abdominal surgery and care for a newborn after the surgery is over!)

But this doesn’t mean that the laboring woman is the only person who might need or want support.

A doula can gently remind the woman’s partner to take “nutrition breaks” to keep up his or her energy for the work ahead.  (I even keep a few Luna Bars in my doula bag so that dads and/or other partners–including myself–have something to snack on!)

A doula can model various massage techniques or other comfort measures so that the mother’s partner can know (and have the confidence) to do them him or herself.

My husband and my doula--my perfect partners!

A doula can reassure a woman’s partner about the “normalcy” of the birth process.  A woman’s sounds, her movements, her intensity, her bodily functions, and her vulnerability during labor might be unusual and even scary to her partner in any other situation.  But during birth, these behaviors are quite normal.  And  doula can help a partner not to be overly frightened or bothered by the work and sights and behavior of birth.

Of course, when birth is not “normal”–when something unexpected, such as a cesarean section and/or an emergency, occurs–a doula can continue to offer emotional support, encouragement, and appropriate reassurance to both the laboring woman and her partner.

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A doula can help you and your partner have a more intimate birth experience.

Some couples are afraid that a doula will interfere in an experience that they want to be wholly intimate and personal.

But unless the couple is birthing in a birth center or at home, they might not realize that birth in a hospital is often not intimate and personal.  Between the triage units, the monitoring machines, the rotating cast of hospital staff, nurse shift changes, paperwork requirements, hospital protocol, and the typical noises and hustle and bustle of the hospital, intimacy can be hard to come by on a labor and delivery floor.

Perhaps surprisingly, adding a doula to the mix can help a couple to protect the intimacy of their hospital birth as much as possible.

For instance, if a woman and her partner are sharing a particularly close moment, their doula can wait outside their room and kindly ask any hospital staff or care providers to wait to enter the room for a few more minutes (barring any urgent needs, of course).

A doula can even help to “set the tone” for a birth by maintaining a calm presence throughout a woman’s labor.  Without a calm and peaceful atmosphere–and labor and delivery units are rarely, if ever, inherently calm and peaceful–it can be difficult to achieve any sort of intimacy, especially during a birth!

And finally, the general support that a doula offers to a woman’s partner can help to make a couple’s experience more intimate and personal.  For when a partner is reassured about the “normalcy” of birth, and when s/he gets some idea of what s/he can do to help a woman who is laboring, then it becomes much easier for the couple to feel closer to one another during labor.

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With a doula present during your labor, your partner doesn’t have to worry about remembering everything s/he learned during your childbirth education class.

Here’s one of my favorite analogies: imagine asking someone to watch a couple games of football on television and then go out the next day and coach the Superbowl.

(Or for those not sports-inclined, imagine asking someone to watch a couple episodes of Bob Ross on PBS and then go out the next day and paint like Monet.)

That’s almost exactly what we ask of dads and other partners when we ask them to attend a childbirth education class and then offer labor support like a pro!

This is not to say that childbirth education classes are worthless.  Far from it.  A good childbirth education class is an enormously helpful, if not essential, component of birth preparation.  But it can be difficult for a person to watch his or her partner in labor–to know that the baby is really, truly on the way–and simultaneously remember everything that s/he learned in class!

A doula can take away some of that responsibility.  She can remind birth partners about what they learned in a childbirth education class when necessary, and then step back so that the partner can demonstrate what s/he has learned.

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Doula support has multiple (and unique) benefits for both moms and babies.

I couldn’t say it any better than this (from DONA International):

Numerous clinical studies have found that a doula’s presence at birth

• tends to result in shorter labors with fewer complications
• reduces negative feelings about one’s childbirth experience
• reduces the need for pitocin (a labor-inducing drug), forceps or vacuum extraction and cesareans
• reduces the mother’s request for pain medication and/or epidurals

Research shows parents who receive support can:

• Feel more secure and cared for
• Are more successful in adapting to new family dynamics
• Have greater success with breastfeeding
• Have greater self-confidence
• Have less postpartum depression
• Have lower incidence of abuse

In a word, doula support is truly invaluable for a woman and her partner!

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Doulas support is intended to “fill in the gaps” of your labor support team–not to replace anyone who is present at your birth.

Doulas don’t replace dads, partners, or even nurses, midwives, or doctors–they work alongside them.

Rare is the instance in which a nurse, midwife, or doctor can offer continuous support to a woman throughout her labor.

Rare is the case in which a nurse, midwife, or doctor can offer even temporary support to a laboring woman exactly when she finds that she wants or needs it.

Doulas can help to fill in these gaps.

What’s more, doulas can fill in knowledge gaps (reminding a couple of the risks and benefits of any recommended interventions), emotional support gaps (reassuring a couple of the “normalcy” of the intensity of birth), and physical support gaps (demonstrating comfort measures such as position changes or massage techniques) that may exist among a woman’s other chosen birth partners.

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So please don’t assume that a doula isn’t for you even if you have the world’s greatest husband/spouse/boyfriend/girlfriend/birth partner extraordinaire!  You might just find that having the right doula present during your labor might offer you and your birth partner just the sort of support that you want and need as you bring your baby into the world.

This post is a part of my “Doulas are for All Types of Women” series honoring International Doula Month.  I’m also giving away a copy of The Birth Partner by Penny Simkin for International Doula Month.  Please see my original post in this series to find out how you can win!

One common misconception about doulas is that they are only for women who plan on having a drug-free (or “natural” or unmedicated) childbirth.

This is simply not true!

Doulas are for all women, even those who are think that they might want to use epidural medication during labor.

Notably, some doulas only take on clients who are planning for a drug-free birth.  This is often not a form of judgment on the doula’s part but rather a matter of a doula preferring the role she plays in a planned unmedicated birth to the one she plays in a planned medicated one.

In most cases, however, you will be able to find a local doula who will support you even if you strongly desire to use an epidural during labor.  (And it is always best to ask prospective doulas about the sort of support they offer when a woman chooses to use an epidural!)

Here are some of the ways that s/he can offer this support:

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A doula can help you receive accurate and transparent information about epidurals before labor

Although they are generally very effective forms of pain relief during labor, epidurals are not without risks or potential negative side effects.  They can lead to anything from a drop in the mother’s blood pressure to fetal distress to an increased risk of forceps and vacuum delivery.

A doula can help to explain these risks to you during a prenatal meeting so that you can make as informed a decision as possible about your birth choices.  Just think–most of us don’t even want to take an over-the-counter pill without knowing its potential side effects before we take it.  The same goes for an epidural!

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A doula can help you to wait as long as possible before getting an epidural

Waiting as long as possible to receive an epidural can help to minimize some of the epidural risks, such as fetal malpositioning or slowing of labor progress.  The physical and emotional comfort measures that a doula offers can help you to cope with contractions until you do want an epidural.  And you might even find that you are coping well enough to forego the epidural and the potential negative side effects that accompany it!

And even if you are completely set on getting an epidural as soon as possible, it is very unlikely that you will be able to receive an epidural as soon as you walk into the door of the hospital!  Most women have to wait–some even up to a few hours–in between requesting an epidural and actually receiving one.  A doula can help you to cope with your contractions during that “waiting period.”

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A doula will remain non-judgmental about your choice to receive epidural analgesia during labor

Some women who use epidural analgesia hear things like this from their friends and family members:

“Oh, I knew you couldn’t do it without drugs!” or “Yeah, I’m glad you weren’t a martyr for the pain!” or “Aren’t you glad that you just gave in and went for the drugs?!”

A doula worth her weight in birth balls would never make insensitive and demeaning claims like these!  And this is partly because doulas don’t think that women need to be rescued from the pain of childbirth.  All women are strong–strong enough to cope with the pain of labor, but also strong enough to choose for themselves (and not under pressure of the hospital staff or friends and family members) when they would prefer to use pain medication during labor.

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A doula can stay with you for the epidural administration

Generally, anesthesiologists will allow one support person to stay with you while s/he administers an epidural.  Some will allow more than one.  But even if only one person is allowed to stay for the epidural, a doula might come in handy if your partner is known to get queasy or faint at the sight of needles, blood, and medical procedures!

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A doula can help you to change positions during your labor

Even though epidurals greatly limit a woman’s mobility, this doesn’t mean that women must lie completely still on their backs when they are using an epidural.  In fact, it is important for women to stay as mobile as possible, even while using an epidural!

Turning from side to side every twenty to thirty minutes, sitting up (with the help of someone else), or simply rotating between side-lying and sitting can help to prevent a common side effect of epidurals–namely, fetal malpositioning, which can lead to slowed labor progress and, often, cesarean section.  A doula can help you to change positions–or even just to remind you to change positions–so that you can avoid these potential side effects.

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A doula will ensure that you–and not the tubes and machines surrounding you–are the center of attention

Some women find that after they receive an epidural, the hospital staff and others around them almost “forget” as if they exist anymore.  The focus seems to turn solely toward the fetal monitor, the blood pressure cuff, and the IV fluids and/or medication–but not toward the woman who is still laboring.

While a doula does not play as active of a role after a mother receives an epidural, her attention is still always turned toward the laboring woman.  Whether she is reminding and/or assisting you in changing positions, “tucking you in” so that you can sleep, reminding you to ask questions about recommended interventions, or simply continuing supporting you emotionally, you are always her primary focus!

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So don’t think that a doula “isn’t for you” if you have your heart set on an epidural.  Doula support can offer benefits to all types of women–even those who strongly desire epidurals during labor!

This post is a part of my “Doulas are for All Types of Women” series honoring International Doula Month.  I’m also giving away a copy of The Birth Partner by Penny Simkin for International Doula Month.  Please see my original post in this series to find out how you can win!

May is International Doula Month!

And in honor of this celebration, I’d like to self-sponsor my first giveaway.  (What does that mean?  Well, the prize is coming from me, and not an outside sponsor, company, or PR firm!)

The prize isn’t huge, but it’s hugely important for pregnant women, their partners, and doulas alike.

What is it?

IT’S A COPY OF PENNY SIMKIN’S ENORMOUSLY HELPFUL AND INSPIRING BOOK, THE BIRTH PARTNER!

Why is this such an important book?  Just read The Birth Partner’s tagline:

A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions

And that’s exactly what it is.

Simkin covers everything from the process and stages of labor to labor comfort measures to birth interventions to the postpartum period–all while maintaining a non-judgmental, encouraging, and inspiring tone!

The Birth Partner has been one of my favorite “birth books,” and I know many, many other women (and men) who have found it to be an invaluable resource.  (In my opinion, the images depicting the different positions and movements for labors and birth–AND the accompanying descriptions of what these positions help to accomplish during labor–are worth the cost of the book alone!)

So what can YOU do to win this book?

Well, you need to help me celebrate International Doula Month!

And you can do this by completing this sentence:

Doulas are for women who…

Easy enough, right?

You see, lots of people are under the impression that doulas are only for women who want a drug-free birth, or women who are birthing with midwives, or women who are birthing at home.  And this is simply not true!

Doulas are for all types of birthing women!

And all types of women need to know this.

You can enter the contest–and let the world know that doulas are for all types of women–by:

1. Leaving a comment on this post, letting my readers know that “doulas are for women who…”

2. Sending a tweet to your Twitter followers, letting them know that “doulas are for women who…” and using the hashtag #doulasforeveryone

3. Leaving a comment on my Facebook Fan Page, letting the “fans” know that “doulas are for women who…”

So each person has three (but only three) chances to enter the contest.  Not too shabby!

(Side note: although I’ll only count one entry per Twitter account, please feel free to tweet as much as you like with the #doulasforeveryone hashtag!)

The contest ends on May 31st (the last day of International Doula Month), and the winner will be chosen at random.

What’s more, I’ll be writing all month long using the “Doulas are for women who…” theme.  (I’ll be kicking it off tomorrow with a post on “Doulas are for Women Who Want Epidurals.”)  I hope that your contest entries will help to inspire some of these posts!

So comment, tweet, and Facebook away!  I look forward to hearing from you–and to giving away this fabulous book!

(Oh yeah.  Void where prohibited, etc.)

Edited to add: Even if you already own a copy of this book, consider winning it for a pregnant friend or doula-in-training!  It would make a wonderful gift!

Doulas and midwives often integrate aromatherapy into their work with laboring women.

Some may mix essential oils (such as lavender or peppermint oil) with vegetable oil to make a soothing and/or nausea-alleviating massage oil to rub on the mother’s back, arms, or legs.

Others may place a drop or two of lavender or rose oil into a warm bath so that a mother can relax in an aromatic tub.

Still others may mix essential oils (such as lavender, rose, or jasmine) with water in a spritz bottle and spray the mixture in the birthing room throughout the mother’s labor so that she can feel the potentially calming effects of the scents.

(Notably, it is always best if a birth attendant–whether s/he is a doula, a midwife, an aromatherapist, a massage therapist, or even an aromatherapy-loving friend–asks the mother before labor what her “aromatic likes and dislikes” are.  These likes and dislikes may even change during the course of labor!)

While all of these uses of aromatherapy during labor have the direct purpose of soothing the mother, alleviating her nausea, or even promoting better circulation and breathing, I discovered one additional benefit of aromatherapy (and of lavender oil in particular) at the most recent birth I attended:

It can provide a calming atmosphere for everyone who enters the laboring room–not just the laboring woman.

At this particular birth, the mother’s care providers (an obstetrician and a midwife) were attempting an external cephalic version (or the manual rotation of a breech baby) before the mother underwent either a cesarean section or an induction of labor, depending on the outcome of the version.

Before the version began, I massaged a lavender oil mixture onto the mother’s temples to promote relaxation and reduce any anxiety she may have had.  (We wanted her to be as relaxed as possible in order to give her the best chance of having a successful version!)

Photo by Heron

Everyone who entered the room thereafter–two obstetricians, one midwife, and one nurse–remarked not only about how nice the room smelled but also about how “soothing” it made the entire atmosphere of the room.

And let me tell you, the room where the version was performed was a triage room, with bright lights, an ultrasound machine, a traditional hospital bed, and about one-hundred square feet of space for all seven people standing in it at the time.  Simply looking at the room gave off no indication of “niceness” and calm!

But the mother remained incredibly calm and relaxed, and the version itself (and everyone who assisted with it) ended up being not only a relatively peaceful but also successful procedure!

After we moved into a labor and delivery room, I continued to use aromatherapy throughout the mother’s labor induction by soaking washcloths in a basin of ice water, to which I added a couple of drops of lavender oil.  When the more strenuous work of her labor began, I used these washcloths as cool compresses on her back, shoulders, neck, and forehead.

And while my intention was certainly and solely to provide comfort to the laboring mother with these lavender-scented washcloths, I do believe that the very aroma of the lavender played at least a partial role in providing a calming atmosphere to the entire labor room and the individuals who entered it.

With lights dimmed and the slightest scent of lavender filling the air, every person who entered the room would enter quietly and would use a low, deliberate speech when conversing with the mother, her husband, or me.  Three nurses, one obstetrician, one midwife, (and one husband and doula!) in a busy hospital, with loads of paperwork to complete and monitoring to perform, with other women birthing in adjacent rooms, surrounded by the machines that go “ping!” and IV poles and birth balls–all took note of the tranquility of the labor room, and even treated it as if it were the mother’s labor sanctuary, so to speak.

And yes, this mother was blessed with fabulous nurses who were pitch perfect for the parts of her labor for which they were present.

And yes, she was blessed with one of the few hospital-based care providers I’ve seen who evaluates a woman’s labor not by looking at the monitors or doing the umpteenth vaginal exam but by watching and listening and observing the woman engaging in the work of birth.

And yes, she was blessed with a supportive husband, who became not only an expert in the “double-hip squeeze” but also a literal and figurative “rock” as the mother held her arm around his shoulders as she birthed their baby into the world.

She was blessed with people who were respectful of her wishes for a peaceful birth!

But I also believe that the low lights and lavender helped every one of us in the room with her to take part in that peacefulness.

The scent was a signal to all who entered the room that even though this was a hospital, and even though this woman was attached to an IV pole, and even though her care providers were medically trained to attend birth, this was not a medical event.

This was a birth, in a place of peace and tranquility, in a place where peace and tranquility are so rarely found.

*I cannot stress enough that you should use caution whenever working with essential oils, especially when using or touching them in their concentrated forms.  If you are pregnant or breastfeeding, please consult an aromatherapist, doula, or midwife before using essential oils as some may be harmful to you or your baby.