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

[Vanfnp]

I feel the greatest of the numerous misconceptions in the original post were the statistics. Perhaps on average, a single birth has the low risk percentages so stated but a VBAC does not. Other criteria will also increase the risk. The OB/midwife has to take into consideration the higher risk and be prepared to deal with any and all outcomes. They plan for the worst and hope for the best. They have to-you can't gamble with a baby's life and 50 uncomplicated c-sections does not prove a VBAC would have been preferable. Not all birthing facilities have the rescuscitative personnel and equipment needed for an unsuccessful VBAC. Do you want to ask a mom to risk it? Can you find insurance to cover you for these risks?? My greatest concern however, is this doula's ethical responsibility to her patient. These decisions are the pathient's, not the doulas, and should be decided by the patient, bearing in mind the advice by the doctor/midwife. If the patient sees things another way, she certainly has the right to find another caregiver who will support her wishes. but it is not the place of the doula (or of the nurse or any other caregiver) to provide their own preconceptions at the delivery. By the time the delivery arrives, these decisions have been made and the doula should support the patient and leave her thoughts on delivery methods to those qualified to make them. It is unethical to do otherwise. And no, I did not insult you; a troll is simply a poster looking for a controversy.

[jrring1019]

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.

THANK YOU!!

[rpbear]

I will reply to each of her thought individually if you like.

1. Oxygen in Labor:

The hyperoxygenation that another poster brought up is the reason. And how intrusive is a o2 mask anyway. Most laboring women have no problem with it if they know it is for the good of the baby. I know it restricts mobility some, but at the point of needing o2 the pt is going to have continuous fetal monitoring anyway.

2. Scheduled Inductions:

At my facility most of thses are medical reasons. If it is that medically needed than they are sent diectly to L&D and not waiting for a spot 3 weeks from now. I also see a lot of pt pushed inductions. "I am so tired of being pregnant, I can't sleep at night, my family is comming into town" and the OB will give in. That is not good practice in my oppinion, but that is the decision made between OB and pt.

3. Baby is getting too big:

The bay grows a lot in the last few weeks. The difference in the head of a 6 lb baby and a 9 lb baby can be an inch or more! This means that the baby can be too big to come out lady partslly. The womans pelvis is another consideration made by the OB or CNM, this is something that needs to be dicussed at the office. A woman has the right to ask why and even refuse a indction that is not medically needed.This is where trust and communication is needed.

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

This is a very broad statement. I don't know the circumstances, if the baby looks fine and labor is progressing then there is no need for pitocin, but if the baby looks fine and mom is starting to get a fever from prolonged rupture, or labor is not progressing at all then pitocin needs to be discussed. Again this is where trust and communication come in. The pt need to discuss things with the MD or CNM. My facility has OB's and CNM'c in house all the time, we are not speeding things up so someone can go home as the poster implied. We want a healthy baby and mom in the end.

5. Diet and drugs during pregnancy:

Nobody is pushing drugs on any pt. If the pt asks for pain medication then they are given a safe dose, and a safe drug for labor. This is very different than taking drugs throughout pregnancy. As for eating durring labor, most women don't have an appetite, and have to be reminded to even drink fluids. They are working so hard at pain control that the other stuff is not at the top of the list. Our CNM will allow small snacks if the pt plans on going natural. Most of the snacks come right back up in active labor. This has to do with the body's physical responce to labor, the digestive tract slows way down so the body can preserve its energy and blood flow where it is needed, just like a marathon runners body would. I have never seen a marathon runner eathing a sandwich while running!

6. It's TOO RISKY:

I don't think homebirths are scary if done with a qualified midwife. I think this is a great option for women who choose it, however I work in a hospital and only deal with hospital pts, so I don't have any personal experience with this.

My facility does allow VBAC's. I think this too is a good option for an informed pt. I think the option needs to be discussed with pt and OB in the office setting and all risk and benefits need to be considered. This again is the trust and communication!

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...":

Coached pushing is not needed with most clients and I rarely use it. I also don't make them be quiet.

8. Premature urge to push:

The urge to push at 4 cm is very different than the urge to push at 8 cm. In early pabor this can cause some swelling and needs to be avoided, this is most easily done by having mom change postion, get in the tub, or walk. At 8 cm I encourage little grunts as this works well for both mom and labor.

9. Internal examinations prior to labor:

This serves two purposes. One is to determine a baseline, so if the pt comes to the hospital and is 4 cm, but was 4 cm a week ago in the office then they may not be ready to be admitted yet, but if they were 1 cm in the office yesterday then very well likely will be admitted. This is especially useful in first time mom's who are not really sure what labor feels like and goes to the hospital for every little cramp. The other reason is to confirm vertex. I know this isn't the best way, but it is the way a lot of OB's and CNM's do things.

10. You need an IV in labor...just in case something goes wrong, we MUST have access to your vein!

Again this is trust and communication with the OB or CNM, if you don't want an IV then discuss this in the office. I have done many deliveries with no IV, and I have started IV's in the middle of an emergency. Know that an IV is a posibility if something goes wrong though.

The pt is in the hospital for a reason, maybe they don't feel totally comfortable with a home birth, maybe they have too many risk factors, the pt needs to trust the care they are getting, and having a doula that is not supportive of that environment is not a good doula. Be a labor support person, and if you have questions about the interventions ask questions, we are happy to explain things.

[mitchsmom]

Lots of good points for discussion. Many of them are great, some strike me as true possibly with more qualifying information.

I am still a student (in my preceptorship in OB)... and I'm a research nerd. Does the doula know of studies to back up the points she makes? I would love to read them & learn from them!! Educate me!

[rn/writer, 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.

It isn't necessary to be demeaning to disagree. Telling someone to "keep her silly questions to herself," is not in keeping with the spirit of this board. Keep the focus on the facts you want to challenge, not on the person you disagree with.

[RaeT,RN]

As always, Deb, well said. There has got to be a trusting relationship between the healthcare team and the pt. I don't have a lot of experience with doulas, but the whole feeling some have that the doula must "protect" our pt's from us bothers me. It is my job to advocate for the pt and to develop a relationship with that pt. YES, some interventions are done purely for convenience, but as previously noted, many are not and are infact necessary.

[JeanettePNP, MSN, RN, NP]

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.

SmilingBlu, I agree with most of what you said, but I want to point out that women don't always have that many options when it comes to choosing a labor/childbirth care provider. Depending on where she lives, her insurance, the hospital she wants to deliver in, etc, she may be limited in her choices. Sometimes a problem comes up towards the end of the pregnancy and it turns out that the person she was using isn't the best one for this particular problem so she's scrambling to find someone else... or you realize that the person you're seeing isn't really the best match but it's too late to find someone else... or the provider promises one thing but the hospital rules demand something else... etc etc.

[jgwe4e]

[color=#202020]3. baby is getting too big: what really is the difference in head size between an 8 pound baby and a 10 pound baby?

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[color=#202020]a lot! i delivered an 8# 10oz baby with no meds. two years later i delievered a 10# 7oz baby with no meds. those two pounds meant the difference between an easy delivery with the first and shoulder dystocia with the second. baby needed to be in icu for resp distress, had trouble weaning to room air, but no other sequelae.

[SmilingBluEyes]

SmilingBlu, I agree with most of what you said, but I want to point out that women don't always have that many options when it comes to choosing a labor/childbirth care provider. Depending on where she lives, her insurance, the hospital she wants to deliver in, etc, she may be limited in her choices. Sometimes a problem comes up towards the end of the pregnancy and it turns out that the person she was using isn't the best one for this particular problem so she's scrambling to find someone else... or you realize that the person you're seeing isn't really the best match but it's too late to find someone else... or the provider promises one thing but the hospital rules demand something else... etc etc.

I beg to differ ...just a bit. I see what you are saying BUT::::

No law or anyone on earth says a woman HAS to see an OB for prenatal care. Midwives are very economical (by comparison) and very good for most low-risk women who want to experience a less "medicalized" and more low-key approach to childbirth. More women need to be educated as to their options. They are not always so limited. They just don't know that often enough....

And if a woman's prenatal course is complicated and high risk, she still has EVERY right to question any intervention or care plan she does not understand or agree with. Again, taking responsibility for one's wellbeing is helpful and critical.

[SmilingBluEyes]

Oh, and yes, let's keep the tone on this thread respectful. The questions posed are NOT "silly" to many of us, even as medical professionals. It sounds very UN-professional to speak this way to anyone. Thanks for understanding.

[JeanettePNP, MSN, RN, NP]

I beg to differ ...just a bit. I see what you are saying BUT::::

No law or anyone on earth says a woman HAS to see an OB for prenatal care. Midwives are very economical (by comparison) and very good for most low-risk women who want to experience a less "medicalized" and more low-key approach to childbirth. More women need to be educated as to their options. They are not always so limited. They just don't know that often enough....

I"m not debating you on this, but midwives are not available in all areas, and many women are disqualified from seeing midwives depending on what the rules are for that particular practice. When I lived in rural Iowa I had only 3 choices for practitioners.

[futureTMA]

Thanks Deb, you have a lot of good insight, as usual.

Obviously, people have some convictions about this and that's good. I agree with SmilinBluEyes in that all people need to be responsible about their healthcare and question things, even routine procedures. We are all not the same.

Going back a bit, the author wanted to say this;

there is a difference between hyperoxygenation and hyperventilation...but the point is that it ISN'T treating the baby and doesn't see improved outcomes.

but I'm ALWAYS open to being shown differently......does anyone have any studies showing that maternal hyperoxygenation has improved outcomes on the neonate...?

In fact...when doing NNR, it's been shown that rescusitating babies with room air is as effective as with 100% O2....

BTW, we didn't see the point of her joining just for this discussion, so I'm relaying messages.

Obviously, she's looking at research to back up what she says even though it's not quoted.