Monday, October 25, 2010

The Doula -- or "Dude-la" -- Post

Some of you might remember reading about one of my couples that accidentally gave birth at home last year.    The plan was to have their doula - who was at the birth - have a doula-in-training shadow her at this upcoming hospital birth.  Frank, the father-to-be, referred to the student doula as "the dude-la" -- she was to be his doula!  His "dude-la" was actually at another birth when Nancy gave birth at home, much to Frank's dismay.  I wish I could take credit for coining this term, but I have to give credit where credit is due.  It makes me laugh every time I think of it.

I always have a couple of doulas that I refer my students to, usually for a bargain price, as my students are usually very prepared for labor and birth.  A bit less work for her -- certainly less educating on her part.  I am very picky about who those doulas are.  Like lactation consultants, doulas are not all created equal.  I knew of a doula in Albuquerque that had a 90% epidural rate! Certainly not the doula I wanted for my students!

The first question I always ask is why she wants to be or why she became a doula.  I am amazed at how many women become doulas because of a personal traumatic birth experience.  They want to help other women not go through what they went through.  That is totally respectable, but not necessarily who I want at my couple's births.  She will often be defensive and looking for things to go wrong.  Her "bad" birth experience led her down this road and she is, in my opinion, trying to right a wrong.

I have been writing about the birth team a lot lately -- doulas, midwives, and OBs.  I've decided that it is 50% of the "requirement" to having a happy birth experience.  Education is great, an absolute must, but if you are surrounded by people who do not believe in your ability to birth your baby without medication or intervention, you likely will not be doing so, no matter how prepared you and your partner are.

If I were looking for a doula, these are things I would want to know:

Has your doula given birth?  (It is hard for someone who has not gone through labor and birth to understand the thoughts that go through a woman's head during labor.)

Where did she give birth and why did she choose that location? (If you are planning a homebirth and you are hiring a doula who has only given birth in a hospital, you might ask her why she chose to not birth at home.  She may, deep down, be fearful of birth.  Or maybe it was an issue with insurance.  Or maybe her husband was too fearful.  Find out why she birthed where she did.)

Did she have medication or intervention?  (When the going got tough, how did she handle contractions?  What seems to be her general attitude about medications and interventions in labor?  Does she really believe that these things are usually not needed?  On the flip side, is she willing to use intervention if required?  Does she recognize that sometimes a woman may need intervention or medication?)

Has she ever been "overdue" and how did she deal with that?  (A woman will naturally doubt her body's ability to start labor on its own towards the end of pregnancy.  Having an encouraging doula by her side, reminding her that her baby and body knows just when the time is right, is crucial.  The "overdue" woman is bombarded with questions of when she is going to finally induce, and her doula will be her rock in refusing induction.)

How long were her labors?  (There is an emotional tug-of-war here.  Most women hope for a short labor, but that is often much harder, physically, than a longer one.  A long labor is not only physically challenging, but very mentally difficult.  It's just interesting to hear her perspective on length of labor.)

What is her c-section rate?  Epidural rate?  (Some things are obviously out of her control, but if her rates are higher than you think they should be, she may not know how to really help a laboring woman - which may be a physical or mental issue.  If she doesn't know her rate, ask her to figure it out.  You'll be doing her a favor, trust me.  She should know this information if she's never figured it out.  If her rates are high, she can evaluate what she can/should do differently, and if they are low, it will help her in talking to potential clients.)

Where is her favorite place to doula?  Hospital, home, or birth center? (Listen to her answer on this one.  This tells you who is the most supportive of doulas at a birth.  It's usually the places where she feels like she has the freedom to work with a couple and her opinions and experience is valued.  These are usually good places to birth.  If a doctor or hospital is not at the top of her list, it's usually because they have policies and procedures in place that make it hard for her to really help you. They are usually resentful of her presence and feel that she is interfering with their work.)

Does she have backup with similar rates and philosophies?  (I don't want certain doulas at my student's births, so I want my doulas-of-choice to have doulas backing them up with similar styles and philosophies.  Things come up in life, and your doula could have the flu the day you start labor.  Ask about her backups.  You will all be more comfortable if you know these things in advance.)

Does she have "time limits" of being away from home (nursing baby, child care, husband's job, etc.)?  This is one reason I don't doula.  I have lots of kids, all attending different schools.  I don't let them ride the bus, so I spend half my day in the car.  I don't live near family to depend on either.   Oh yeah, and I have a husband with a demanding job.  Lastly, I don't have the patience necessary to be good doula!  If she does have "time limits" she may be very distracted.  Know what the issues are and how she deals with them.  For example, she may need to pump breastmilk every 4 hours during your labor.  If you are fine with that, great.  If that will drive you crazy, she's not the doula for you.)

Lastly, ask her what she literally brings to a birth? (One of "my" doulas is a massage therapist so she doesn't bring a lot of physical items to a birth.  She brings her hands, ready to work.  She knows acupressure points that stimulate labor and actively uses them throughout labor.  Other doulas have a bag that they bring, full of "birth toys" to help throughout labor.) 

It's nice to know what your doula brings to a birth, both literally and figuratively.

I hope this list helps you in your search for a doula.  They are such an important part of the birth team.  I see more epidurals and c-sections at births without a doula than those than have a doula.  And if your husband is resistant and wants the job all to himself, start calling the doula a "dude-la" and remind him that she is there as much for him as she is for you!

Monday, October 18, 2010

The OB at 38 weeks

I am not out to make anyone a bad guy here.  OK, maybe a little.  I have worked as a Natural Childbirth Educator for long enough to make some generalities and feel pretty comfortable with saying them.  I am fully aware that there are exceptions to what I am about to say, but they are so few and far between.  I hope what I am about to say will be listened to and not just heard.

There are two types of maternity care:  the Medical Model and the Midwifery Model.  Briefly, the Medical Model perceives pregnancy, labor, and birth as a disaster waiting to happen;  something a woman needs to be rescued from.  Medicine improves upon the "natural" process.  Labor is all about the cervix and birth canal, always looking for something to go wrong.

The Midwifery Model of Care, on the other hand, trusts a woman's body to grow her baby, start labor at the appropriate time, and labor without time constraints.  A midwife takes into consideration, not just the cervix and birth canal, but the entire woman and her environment.  Birth is as much mental as it is physical.  Medical doctors almost always ignore this fact, usually because the hormones are not working properly when a woman has an epidural.  They just don't see natural normal birth often enough to know what to do -- or more appropriately, what not to do! 

So when couples come to take my Bradley class, I worry about those that have an OB.  And rightfully so.  Most of them will see the light and switch to a midwife, but sometimes the couple is fed so many lines by their OB and hospital nurses, they don't switch, believing their doctor is different. 

From the L&D nurses:

"We have birth balls, showers, tubs, squat bars, dim lights -- everything you want for your natural birth."  (In labor, these things are nowhere to be found.  Only one room has a tub that works, no one can find the squat bar, lights are bright so the doctor can see -- it's all about him, right?  The atmosphere is not what was promised.)

Some of my favorite lines from OBs are:

"As long as everything is going fine, you can do whatever you want."

"As long as your water isn't broken, you can walk around as much as you want."

"We can do intermittent monitoring as long as baby is handling labor okay."

"We don't need to talk about induction unless you are more than a week past your due date."  (No one thinks they will be 'overdue' when they are pregnant.  No one.  They believe this won't apply to them.)

Don't these sound great?  I've got a great OB, right?  Did you hear the clause in each statement?  Remember, an OB is trained to look for things to go wrong.  Statements like these pacify the pregnant woman at monthly/weekly appointments because it seems like she is hearing what she wants to hear.  The problem is, an OB can make up all kinds of reasons to keep you on a monitor in labor, or restrict food and water, or induce labor for a million different reasons.  Seeing this as often as I do, a local doula called this the "Bait and Switch."

Something happens at 38 weeks with an OB, where all-of-a-sudden pregnancy becomes very dangerous.  The placenta starts to deteriorate, amniotic fluid levels rapidly drop, blood pressure is through the roof, and vaginal exams must be done to ensure that your body knows what to do.  Oh yeah, and your baby is getting much too big to fit through your pelvis.  We either need to look at inducing right away or just scheduling a c-section to save you from having to go through the trials of labor.  You'll probably just end up with surgery anyway.

I wish I was making this stuff up.  I'm not.  I see it all the time.  If you stay with an OB who makes "reassuring" statements with a clause and you ignore these red flags, and then you have a c-section, you will always wonder if you really "needed" surgery.  If you change care, even at 39 weeks, to a midwife who trusts birth and encourages you along the way, and then end up with surgery, then you probably did need it. 

I recently had a mom who changed care from an OB at 39.3 weeks to a group of CNMs.  Her baby was over 10 pounds and she pushed for nearly 4 hours.  She had back labor most of her labor and did have an epidural.  Had she stayed with the OB, I am 100% certain she would have had surgery.  Her previous hospital has a 60% c-section rate and they would never have allowed her to push that long.  Sure, she did not have an unmedicated birth, but the switch saved her from surgery.  A good move.

Be on the lookout for these statements from your OB.  The end of pregnancy is so exciting.  You are about to meet your baby for the first time!  A good care provider will reassure you that your baby and body know just when the time is right for labor to begin.  Your care provider should fill you with reassurance, not fear.  And that, really, is the difference between a good care provider and a bad one.

Monday, October 11, 2010

Want an Unmedicated Birth -- Or Even Just a Vaginal Birth? Hire a Midwife and a Doula

I have recently had a bad run -- lots of cesareans and epidural births.  I've thought about them a lot over the last several days and weeks, and there are some significant numbers that I want to share.

Up to now, my stats have been about 79% of people that take my class give birth without medication.  14% have a cesarean, and about 7% have an epidural, the majority of the time to avoid a c-section.

These last few months have been the worst statistics I've had in over seven years of teaching.  It's hard for me to put this out there, but I've gone back about 4 months to include a couple of classes and several DVD couples.  There are some interesting things to note, and I hope this improves future outcomes.

In the last 4 months, I've had 23 couples give birth.
10 had unmedicated vaginal births.
5 had epidurals (but still had a vaginal birth).
8 had c-sections. 

Let's break this down, starting with the 10 unmedicated vaginal births.  (This is what everyone was shooting for.)
6 hired midwives (mix of CNMs and CPMs).
4 hired an OB.
6 hired a doula.

Of the 5 epidural births:
3 had a midwife.
2 had an OB.    
Only one of these women hired a doula.  
It should be noted that a few of these women started with OBs and switched to midwives.   Length of labor and/or pushing would have certainly resulted in c-sections had they stayed with their original OBs and hospitals.

Of the 8 c-sections:
2 had a midwife.
6 had an OB.
Only 2 of these women hired a doula, and only one had her doula present.
Obviously, these c-sections happened for a variety of reasons, some valid, some not-so-much.  Can't ignore that 80% were with OBs.  Honestly question if they would have happened with a midwife.

Summary:  If you want an unmedicated birth, your birth team is crucial.  All the education in the world won't matter if you have a doctor who is determined that you or your baby "need" a c-section.  As for a doula, the statistics speak for themselves.  A woman who has the support of another woman in labor will almost always have a better outcome, or at least feel better about doing all that she could do to prevent having an epidural or a c-section. 

If you are birthing in a hospital, you need to hire a midwife instead of an OB and you need a doula by your side.  End of story.