Doula Thoughts on L&D (long)

[futureTMA]

i wanted to post this to get feedback from nurses. i'm interested in what the "rebuttal" will be. i myself am a nursing student.

i post this with expressed permission from the author.

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[color=#202020]deep doula thoughts

[color=#202020](or ‘things that make you go “huh”?’)

[color=#202020]by stephanie soderblom cd cld ccce cbc

[color=#202020]i am a doula. what this means is that i have spent the last 10 years helping moms and dads become moms and dads. i like to call doulas, “people helping people out of people”. however, over the years i’ve seen many practices that are “standard” and “routine” that i have found just doesn’t make sense at best, and appear dangerous at worst.

[color=#202020]the following are some of my thoughts on some of the routine procedures that have left me wondering “is anyone thinking about this??”

[color=#202020]1. oxygen in labor:

[color=#202020]we’ve all seen it…mom is laboring and baby has some funky/questionable heart tones. first thing they do, of course, is change moms position. the next thing they always do...is [color=#202020]slap oxygen on moms face. look over at the pulse oximeter and it shows [color=#202020]mom's o2 level as being 100%...before we added oxygen. ok..if mom's oxygen saturation is already at 100%....what do they think having her breathe more oxygen is going to do other than freak her out?? in what way can it possibly benefit her?

[color=#202020]2. scheduled inductions:

[color=#202020]parents are told that they will be inducing next week...for [fill in any reason]. [color=#202020]this is an elective induction, not a medically necessary one. that’s a pretty bold statement…how do i know this without further information? because if they were really worried about mom or the baby,would they really send her home and wait 4 days before inducing her? and if they aren't worried...then couldn't they recheck on them in 4 days and then decide a course of action?

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[color=#202020]3. baby is getting too big:

[color=#202020]parents are told that they need to induce at 39 weeks because the [color=#202020]baby's getting "too big". [color=#202020]ok..so...how much do they think the baby's head/shoulders will grow in [color=#202020]that extra week or two weeks? they talk about baby's weight...but what [color=#202020]about baby's head and shoulders? babies don't get stuck at their [color=#202020]chubby little thighs, hung up by their adorably dimpled butts ....

[color=#202020]what we have to work hard to birth as heads and shoulders, not their chub. to help with the delivery the baby’s head is made to mold, the pelvis will expand and open up… [color=#202020]what growth do they think will occur those last 1-3 weeks that will change the outcome of the delivery? what really is the difference in head size between an 8 pound baby and a 10 pound baby? (double chins don’t count!

[color=#202020]4. “we don’t know how long baby will continue to tolerate...”:

[color=#202020]parents are told that they need to give her pitocin because, although [color=#202020]baby "looks good now, we don't know how long baby is going to tolerate [color=#202020]this..." isn't that true from the moment of conception? we never know [color=#202020]how long baby is going to be happy.....all we can go off of is now..and [color=#202020]right now baby is happy and everything is fine. if everything is [color=#202020]fine...why are we in a hurry? why rush it? if mom and baby are fine with the way things are right now – then it must not be because of mom and baby that we need to speed things up, right?

[color=#202020]then who is it for? to this i have an answer, but would prefer that each reader is able to answer this question themselves. if it’s not for mom and baby, then for whom are we wanting to hurry things up for?

[color=#202020]5. diet and drugs during pregnancy:

[color=#202020]women are told to fanatically watch what they eat or drink....watch out [color=#202020]for tuna because of mercury, deli meats could have listeria, don't walk i[color=#202020]nto a restaurant that has smoking because you might inhale second [color=#202020]hand smoke, no sushi, no alcohol whatsoever, no caffiene. when you are pregnant you are making decisions for two and should be meticulous about what you put into your body.

[color=#202020]when a baby is getting ready to be born, aren’t you still pregnant? do the rules stop applying? yet on the day that the baby is to be born, the most important day that this child will have, much more important than the day she was 20 weeks 6 days pregnant…much more transformation than on the day she was 32 weeks 4 days pregnant…an even more dramatic day than the day she was 8 weeks 1 day pregnant. on that day we will encourage mom to take an average of 7 – 9 different pharmaceuticals (including things such as stadol, demerol, fentenyl (“100 times more potent than morphine”), bupivicaine) and prevent her from eating anything at all and we will call that “normal” and “safe”.

[color=#202020]6. it’s too risky:

[color=#202020]we will routinely take women and artificially rupture their water, introduce catheters and monitors to the inside of the uterus, add pitocin into a woman, give her anesthesia, induce her if she gets too uncomfortable, give an elective cesarean if she just strongly requests it.....

[color=#202020]but then we will say that a vbac is too risky and shouldn't be done. after all the risk of a baby dying during any type of delivery is [color=#202020]0.12%...the risk of a baby dying during a vbac is .20%. not a huge [color=#202020]difference. risk of dying from a uterine rupture is .0095%, risk of dying from a repeat cesarean is .0184%. but a vbac is too risky.

[color=#202020]lets take this over to a homebirth. we will do all of the interventions listed in the first paragraph (things we know dramatically increase the risk to mom and baby) but say that homebirths are scary! after all – what if something goes wrong! we forget how very often things went wrong because we were messing around with things – how often things go wrong in a hospital that wouldn’t have gone wrong at home because we wouldn’t have been inducing her, wouldn’t be giving her those pharmaceuticals, wouldn’t be restricting her eating, wouldn’t be breaking her water…

[color=#202020]7. “take a big deep breath like you’re going under water, chin to your chest, curl around your baby, and push down – 1, 2, 3, 4, no noise, 6, 7, 8, 9, 10…good pushing, now deep breaths, breathe for your baby…”:

[color=#202020]women are told to hold their breath for 3 counts of 10 while pushing, [color=#202020]not to make any noise or let any air out.... [color=#202020]then are told they need to "breathe for their baby!" between [color=#202020]contractions...between....when there is no pressure on the baby. but [color=#202020]they don't need to breathe for their baby during the contractions?? [color=#202020]i ask every pregnant woman right now to get a watch or timer with a second hand – and hold your breath 3 times for 10 seconds in a row and see how it feels. [color=#202020]now do it again…after walking for 10 minutes on a treadmill. how does it feel?

[color=#202020]as for the no noise thing - ...i've heard them say, "your voice is your [color=#202020]power...if you are making noise you are letting your power out... [color=#202020]here are some mental images for you - "think 'karate'...think 'olympic weight lifters'...think 'us open tennis players'. you'd think if your voice was your power then karate instructors would be saying "sshhhhhhh!" and the karate studio would be absolutely silent. wouldn’t olympic coaches have discovered that fact that you can lift more or gleem more power from being silent?

[color=#202020]8. premature urge to push:

[color=#202020]women are told that they must not push before they are fully dilated....the pressure down on the cervix could make the cervix swell. not even little grunts! no no, breathe, don’t push! b[color=#202020]ut then, an hour later, she is given pitocin to strength then [color=#202020]contractions, they never worry that it will make the contractions so [color=#202020]strong that it will swell the cervix. she feels nauseated and is throwing up, and they don't worry that that will swell the cervix. isn’t the point to have good strong pressure down on the cervix? [color=#202020]i’ve heard some women be told that they might tear the cervix! yikes!! that would stop me from wanting to push, too! but if that was the case then wouldn’t it hurt more to push not less? most women who are pushing are doing so because it feels better to push…wouldn’t think that tearing your cervix would feel better than not, do you?

[color=#202020]9. internal examinations prior to labor:

[color=#202020]why are we checking you? what is the point? [color=#202020]oh yes, i hear you answering now…it’s to see if you’re going to have the baby soon. [color=#202020]first off, if you’re full term (which i hope you are if you are having internals!) then the answer is a resounding yes! you will be having your baby soon! (and i don’t have to stick my hands inside of you) [color=#202020]next, an internal examination prior to the onset of labor gives no information that is beneficial or useful. [color=#202020]wow…pretty bold statement, yet true. you are checked and found to be zero dilated and zero effaced. you could have your baby that night. (that was my third child) or you could be found 3cm dilated and 75% effaced and it could be weeks! (that was my second and fourth children) so if dilation and effacement aren’t going to tell us when we are going to go into labor, why are we checking?

[color=#202020]wait, not fair…that was my question!

[color=#202020]10. you need an iv in labor…just in case something goes wrong, we must have access to your vein!

[color=#202020]rather than question this statement, i’m simply going to relay what happened with some students i taught a childbirth series to many years ago. he (the expectant father) happened to be an emt-paramedic. this couple was doing a hospital tour so that they could become familiar with the hospital they intended to have their baby in. the nurse showed them the triage area, then showed them the labor and delivery rooms, explained that this is when they would get their iv…

[color=#202020]the emt dad said, “umm, what if we don’t want an iv?”

[color=#202020]nurse replied, “it’s standard…what if something goes wrong? we must have access to your vein and what if it takes a while to get the iv started? it can be difficult sometimes to get it started…what if we can’t get it started and we’re trying to get an iv in while your baby is having problems??”

[color=#202020]the emt dad looked her straight in the eye and said, “are you telling me that i can start an iv in the field, at night, in the rain, inside a vehicle that has been flipped over on a patient who is critical and bleeding out…and you are concerned about starting an iv on my healthy wife in your brightly lit hospital??? that frightens me.”

[color=#202020]hee hee. i’ll just let that story sit with you for a while.

[color=#202020]maybe i’m too logical…or maybe there will be one person who reads this and starts to think about this thing we call ‘childbirth’.

[color=#202020]see…i’m not just logical…i’m a dreamer, too.

copyright 2006

[rpbear]

All I have to say to the author is you are trained in labor support, not medical management of labor. These are two very different and helpful bases of knowledge. I do agree with the part about elective procedures, and the part about introduction pitocin just to speed things along, and the coached pushing for a natural labor,but some of the other stuff I am not going to touch because it will get me too worked up!

I love Doulas, they are very important in the labor of a woman, but I don't like doula's who question everything I do and make the parents think that the medical staff are stupid and can't be trusted. This is not productive in obtaining the goal of the woman in labor, a safe delivery in the way she chooses. We need to work together as a team, and follow the lead of the family, not push our personal beliefes on the family (be it medical or natural).

[futureTMA]

Thanks for the feedback, rpbear. Although I can't speak for this woman, I know doulas love nurses that support them and the mother. These nurses are usually highly sought after. They don't have a problem with nurses or nursing (unless they needlessly interfere), but with routine procedures that have questionable effectiveness and health.

To clarify, what I'm looking for is discussion and evidence to rebut her points? Is it really true? If not, why not?

Thanks

[jrring1019]

i wanted to post this to get feedback from nurses. i'm interested in what the "rebuttal" will be. i myself am a nursing student.

i post this with expressed permission from the author.

____________________

1. oxygen in labor:

o2 in labor is still approved for use by acog/ awhonn as a method of improving fetal outcomes. by hyperoxygenating mom, you increase fetal po2. if we didn't do this, we would not be following standard of care and that would come into question when we were being sued.

in what way can it possibly benefit her?

it is intrauterine resusitation...for baby, not for mom.

2. scheduled inductions:

aka elective inductions are usually decided on by both ob and pt. pt most likely is tobp and only wants their doc to deliver, so induction is scheduled when their doc is on call.i just take care of 'em.

3. "baby is getting too big:"

on the one hand i have seen a "too big'' weigh 7 pounds....oops.

"how much do they think the baby's head/shoulders will grow in that extra week or two weeks?"

i don't know the statistics, but you see one bad shoulder dystocia and you also would error on the side of caution.

4. "we don't know how long baby will continue to tolerate..."

usually means baby is having decels, not that everything looks good.

5. diet and drugs during pregnancy:

"on that day we will encourage mom to take an average of 7 - 9 different pharmaceuticals (including things such as stadol, demerol, fentenyl ("100 times more potent than morphine"), bupivicaine)"

i have never, ever offered a pt 7-9 meds. also meds listed are not standard. i only give nubain/epidural when the patient asks for it.

"and prevent her from eating anything"

many of our docs let them eat, we just keep a large bucket close by. if she is really hungry, she is probably in early labor and what doula brings her client to the hospital that early?

9. internal examinations prior to labor:[/b][/size]

[color=#202020]why are we checking you? what is the point?

so the doc knows if the cervix is ripe for the elective induction the pt wants.

i skipped some, but i am done....

[BonnieSc]

I'm sort of concerned that this person is a childbirth educator, because she doesn't seem to have a great understanding of everything involved in labor... I'm a doula as well, and about as non-intervention as you get (or so I thought), but there were definitely some points here I disagree with. For one, "people helping people out of people" makes it sound like she's assisting with the actual delivery. That may not sound too important, but many people don't really understand the doula's role, and we shouldn't confuse the issue further.

Re drugs: giving analgesics during labor is totally different from the healthy diet / drug and alcohol abstinence advised during pregnancy. Taking substances (or missing nutrients) while you're pregnant impacts the fetus's development; the consequences are incredibly far-reaching. This is comparing apples and oranges.

Induction: In the last few weeks of pregnancy, all the baby does is GROW. Some babies are too big (yes, even with molding), especially due to gestational diabetes. I'm not necessarily pro-induction, but if I had to choose between an induction and a c-section, I'd take the induction. Not saying the c-section would be necessary, but in most hospitals, well, it'd be done.

The author says at the end "maybe I'm too logical"--I don't think she's logical at all; I think she's undereducated. Also, her tone and writing style make her sound more ignorant that she probably is. So this is why many nurses are uncomfortable around doulas...

[Vanfnp]

The doula post is wrong on so many levels the poster has got to be a troll. Any 1st year nursing student can rebut most, if not all, of said troll's "points". My advice: a doula should function as a doula-leave the health issues to the healthcare team-doctor, L&D nurse, midwife, etc. If you do, chances are you will continue to be welcome at the facility.

[futureTMA]

Vanrn, thanks for the insult. I was hoping we could have a healthy discussion without resorting to name-calling and sterotyping.

[futureTMA]

I emailed the author the responses, and here's what I got back:

my "thoughts" were not about nurses...they were about policies and proceedures that nurses are taught and/or told that they need to follow...as well as proceedures and policies doctors have in place.

The idea of "hyperoxygenating mom"...and it being "intrauterine

resuscination" for the baby....is completely bogus. hyperoxygenating is called hyperventalating...and you do NOT want a mom hyperventalating while in labor. We try hard to prevent this..because we know that this is bad for baby. NOt just during labor..but it is bad for baby for the first few

days with higher instances of apnea in the neonate.

I know it's what they are told..and I know all about standard of care...but I'm questioning WHY it's standard of care since it is NOT beneficial at all.... not questioning the nurses that follow the order...

baby too big..."you see one bad shoulder dystocia and you would err on the side of caution". I have..it's scary..and it's not prevented by inducing.

don't know how long baby will tolerate...usually means baby is having decels? Not where I am. I hear often, "Baby is doing fine...but we don't know how much longer they will be fine...."

it's not because baby is questionable.

drugs in pregnancy:

she's right..I should have listed some of the other drugs she might be given that day, such as misoprostol, pitocin, lidocaine....not just analgesics and epidurals.

Eating in labor..

"what doula brings her client to the hospital that early?"

It's not up to me when they go to the hospital..maybe they are at the hospital for their elective induction........

some of her other rebuttals..I agree with. internal examination..to see if she can be induced. *nods* but then you could just do an internal before scheduling an induction..why are 36 weeks??

Oh..and for the record...I know many nurses that have the same

frustrations I do. My paper is NOT against nurses!!! It's against these policies...

She also added that she would be willing to discuss this with anyone on her message board. You can PM me for the address. She said, "and any and all comments are welcome!! With open arms and with complete respect..!!!"

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My $0.02 - I like to "boil things down" and to me what this comes to is liability. Hospital policies, medical procedures, professional organization policies, HMO policies, etc. are created to protect against lawsuits and not just in OB. I understand this but it is not in the best interest of individual and society's health or economy.

[SmilingBluEyes]

I think there is some VERY valuable food for thought there. Really, if all health care providers COULD be trusted implicitly to have the best interests always at heart of their patients/clients, such thoughts would not be needed to be published, would they? It communicates to me, at least, there is a lot of perceived mistrust and worry on the parts of the community out there, of health care providers, and in particular, hospitals. That is a shame, but I would be a liar if I said it were baseless!

Also, I also think it comes down to geniune trust between patient/client and health care provider. The patient has a very clear right (and, I daresay, responsibility) to know *why* certain interventions are being done and to be well-versed as to the risks versus benefits of each one. Trouble is, many people either do not know to, or do not bother, to take the time to be aware of these things and question them as they come up. Also, there is the issue of patient vulnerablity in the hospital setting, where little to no control is perceived to be in her possession while she is there. It's true: the hospital environment is very foreign and intimidating to most patients and family members, at least, until they are made comfortable, kept well-informed and "in the loop" regarding their care. People have the right to these things, from where I sit, and I do my best to ensure they get them on my watch.

Still others are afraid to question the authority of their doctors, clearly, at any point in pregnancy, which is sad. I think a doula serves as a great support and resource person and can empower a patient/client to take the initiative to ask the right questions and know the risks of each intervention being offered----and also know she can refuse---if need be.

I also think we may be trying to paint too many diverse situations w/a broad brush. Clearly, there are times when medical intervention is not only indicated, but absolutely NECESSARY for wellbeing of mom or baby , or both. This is where TRUST comes into play. If a patient/client TRUSTS her health care provider, she then knows that the things he/she suggests are not only beneficial, but she also knows they outweigh any associated risks.

I have to ask, if a patient/client can't trust her health care provider enough to know to ask "why" (or other key questions), then why is he/she continuing to see this person? Perhaps, the informed consumer would do well to ask the right questions EARLY ON in pregnancy, and get a "feel" for the climate at her OB/Midwife's practice. It would be helpful to see if they are a good fit for her and her family. If not, she and her partner always have the right to find someone who IS a better fit and whom she/they can trust to do right by them, without having to worry at every turn. There are alternatives to hospital birthing, also, such as midwife-run centers or the home; things some people do forget or are never told.

To me, it's a matter of being an informed consumer of health care and , even more importantly, having a trusting relationship between client/patient and health care provider. It's definately a two-way avenue we travel here!

[futureTMA]

Wow, many thanks for your great post, Deb.

The trust "angle" hadn't occured to me but is certainly needed.

[SmilingBluEyes]

I think "Trust" is the crux of the whole matter!

[gr8rnpjt, RN]

If the doula had more of a medical background she would know the difference between hyperoxygenation and hyperventilation. This is the one glaring error in her observations that make me aware that she should stick to rubbing her pateints back and helping her change positions. She should leave the real complicated decisions to the medical professionals and keep her silly questions to herself.