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

[Spidey's mom, ADN, BSN, RN]

:imbar Nope. I just remember being told by both our speaker and some of our nurses who are NRP instructors that the new guidelines are going to say to start the blender at 21% and just increase as needed. I definitely agree on using a pulse oximeter rather than the baby's color, which is why I think we really need new probes! I don't agree with blowing 100% 02 in the face of every full term baby who isn't bright pink, so long as they're breathing well.

I do think oxygen is overused in the delivery room, both for preemies and full term babies.

That is about where my agreement with this particular doula ends.

The instructor in the class I took last year said the same thing and that the standards would probably change to reflect room air resuscitation.

We don't give many drugs to women in labor - maybe very occasionally Demerol (I had it 23 and 21 and 16 years ago - hated it and didn't make the pain go away at all, just made me rummy between uc's). We sometimes given Fentanyl. We mostly do epidurals if the woman cannot tolerate the pain and asks for relief. In fact, most women come in knowing they want an epidural when the pain gets intense.

As to eating - we allow clear liquids (that includes of course jello). Most women are not hungry while in labor but ravenous after.

We use nasal canulas unless there is a true emergency with the mom/babe. Not masks.

Alot of these changes are coming about because the laboring mom wants them - inductions, epidurals, etc. It isn't all about "natural childbirth" anymore, at least where I live.

steph (not the steph who wrote these questions by the way;)

[BabyRN2Be]

Another comment: I've been on both sides of the fence. Not as an RN per se, but I've been raised in a strong medical community. My mother was an RN, I have many friends who are RN's, and I am a CNA.

I'm also a doula. I've been through two doula training conferences. The first one I went to gave some very caustic comments on the MD's and nurses. That one really got to me. The instructor stated that docs will do these interventions to get out of the hospital on time. This to me sets up conflict between the medical side of things and the doula side of things. This is unfair.

I wish that some doula instructors would know their bounds, and understand that we are all working toward the same goal on both ends. While I do agree that some interventions are not necessary, there are interventions that are done with good reason. I wish that some doulas would understand that and not be so gung-ho that it offends the medical team. Some of these doulas have made so many waves that there are nurses who immediately get defensive when they see the family has hired a doula.

In my practice, I do tell them the pros and cons of interventions, but when it comes down to it, they are the ones that make the decision. And if things are really bad, I'll recognize it and tell them that I believe it's in her best interest to have a certain intervention done - that the goal is a healthy mom and baby. If things do are not going well, I do my very best to show the mom the positive aspects of the experience. For example, I'll say, "Wow. That nurse was really on the ball and I'm glad she caught that. This could have harmed your baby." Or "You know, I know that you had to have a c/s but the staff handled it in the best way." And I'll then bring out the positive aspects of what the staff did, and then emphasize that this was not her fault. I do see labor as possibly fraught with complications that couldn't have been seen beforehand.

One more thing: if Stephanie had put forth her opinions at the place where I do my volunteer doula work, she'd be out the door so fast her head would spin. Sometimes we really have to prove to our nurses that we aren't there to build distrust between the family and staff, that we are there to supplement their job and we are there to make things easier for them. For example one I was called to help with a case in which a young girl was screaming for no reason and was constantly on the call light every 5 minutes (this is not an exaggeration). When I got there, I was able to help her and the calls to the desk stopped in frequency to once an hour or so. I was told so many times by the staff that they really appreciated my help as this girl was depleting their resources. I'm so glad that I made a difference to both the family and the staff.

However, it starts with doula training. I believe that some instructors should not paint the medical personnel in a negative light. This builds distrust from the start. It would possibly eliminate a lot of misunderstanding if the doula's role was clearly defined to the nursing staff, and the doula herself should take the responsibility not to cross that line.

This is just my opinion, throwing my into the jar. And I'd also like to thank the nurses with their patience with me when I ask questions about what they are doing. It really is a great education.

[BabyRN2Be]

Posted twice. Sorry about that.

[babyktchr, BSN, RN]

Wow...interesting thread. I will only add that I have had two very negative experiences with doulas...one that sat in the rocker and did not assist the patient whatsoever except to say that she was out of control...and another who tried to prevent me from intervening in a prolonged decel situation that quickly proceeded to bradycardia and a stat c-section for a prolapsed cord. As I put O2 on she took it off and made mention of the MATERNAL O2 being fine. It all was a nightmare.

I think doulas are great..when they work. I just have not had the experience where they have...so I cannot really speak to anymore than I have. I think having someone there to really support the mom in labor is wonderful. Any OB nurse I am sure will tell you that they wish they had MORE time to spend with a laboring patient and really give that support and perhaps reduce the amount of interventions that are occuring with more frequency. Nursing has moved from patient care to documetation and caring for way more than you can handle.

Any book on fetal monitoring...Murray, Simpson, AWHONN's Text, will cite O2 use in intrauterine resusitation. INTRAUTERINE is the difference. I know that NRP will be soon revamping and changing but that is EXTRA uterine life. Its a whole 'nother ballgame when they are still inside.

[futureTMA]

Thanks for all the response!

I'm a little behind . . .

can you please please please thank the person who posted the study for me...I found it very interesting and it's the first time in years anyone has actually showed me any research showing the effectiveness of O2 in labor for the mother. Thank her for me...really.

As for NNR....maybe it's a regional thing but while I've seen "NPR" used, around here I've seen NNR used more often and in the paperwork for my state licesure as a midwife it's listed as NNR. (neonatal resuscitation).

As for teaching this stuff....

No, I do not. =) I don't teach my students (or clients) about neonatal resuscitation - nor am I working in the NICU. If I do hospital births it's totally 100% nonclinical...

only place I do clinicals is in a homebirth setting...and for those settings, NNR has been shown to be as effective with room air as with 100% O2 (big debate among homebirth midwives is the necessity for O2 for a baby needing help). I'm not talking about doing PPV on a 28 weeker with room air or anything like that....

and room air IS used for resuscitation...just not in hospitals. =)

But back to the teaching..

I teach childbirth preparation classes...I don't teach midwifery

courses..and I don't teach clinicals..and I don't teach nurses...and I don't teach NNR classes. And the things in my paper are the things that I would NEVER say to a student in one of my classes..which is why I wrote it down. Because it's been brewing for years and years and years and there are so many things I would never say but that make me cringe. I've seen women lied to directly ("epidurals don't ever cause

fevers" "there's no risk to us breaking your water") to women making scary choices ("I just have a small pelvis and I'm sure the baby would never come out so I've asked the doctor for a cesarean...I'm 37 weeks, so I'm sure the baby is ready to come out..")

But I don't tell people what to do...I don't even encourage. I don't teach people that O2 in labor is a scary thing...and, in fact, I help put the masks back on their face when they take it off while they push. I don't tell them not to induce, I simply give them all of their options. I don't teach one way to give birth...I educate and give them options.

Who is the person who says that she knows me!!!?? *laugh* I'd love to know who that is! As for medical training...depends on what she means. I'm certified in NNR...I have taken advanced fetal heart tone training...I apprenticed under a homebirth midwife for a year...had classes in things like venipuncture...and I'm about 11 months out (estimated) of when I hope to complete my LM. I'm not going for CPM...but I am going for my LM which is a little different. I could get my CPM..it's just not my first focus as I never expect to move out of state so I'm just focusing on my LM right now.

I am curious, however...the person that says that she knows me

personally and says that I have some strong beliefs of how things SHOULD be in labor and that it spills out to everyone....what my belief is that is spilled out..?

WhatI mean is... she knows me personally...is the feeling that she gets from me that spills out...is it that every birth should be like MY birth? Is it that every birth should be unmedicated homebirths...or that every birth should be in a car behind the McDonalds...or that every birth should be induced...

or does she feel that my strong belief be that it be up to the mother and that she have the power and right to choose what's right for her?

Because that really IS my strong belief...and I don't want the wrong ideas coming through.

I really hope it's the later...

"I don't teach one way to give birth...I educate and give them options." This is a verbatim accepted definition of doulas.

[Gompers, BSN, RN]

Any book on fetal monitoring...Murray, Simpson, AWHONN's Text, will cite O2 use in intrauterine resusitation. INTRAUTERINE is the difference. I know that NRP will be soon revamping and changing but that is EXTRA uterine life. Its a whole 'nother ballgame when they are still inside.

Oh, believe me, we understand. I'm all for giving moms 02 when the fetus is in distress if it's going to help! It's when the baby is born, studies are showing that a baby in respiratory distress is going to do just as well with 21% as they as with 100% oxygen pumped into them via mask or ETT.

[Spidey's mom, ADN, BSN, RN]

Oh, believe me, we understand. I'm all for giving moms 02 when the fetus is in distress if it's going to help! It's when the baby is born, studies are showing that a baby in respiratory distress is going to do just as well with 21% as they as with 100% oxygen pumped into them via mask or ETT.

That is what I meant too.

I'm a bit uncomfortable with this third person conversation though - why doesn't Stephanie just register and chat?

steph

[mitchsmom]

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

I asked about research in a previous post, as it was not obvious to me that the reading was based on research, particularly since the piece is presented in a casual style of writing.

Maybe she should write a Henci Goer-esque book to get her word out!

I sure wish the references were quoted in her piece - I have access to my university's databases for just a couple more weeks and would have loved to print out some of it to have as I start working in OB. The piece is good for conversation though!

[SmilingBluEyes]

I agree w/Steph. The person saying all this might be better-served addressing our comments herself here. All this third-person stuff makes me squirm, too.

[NoMoreStudying]

2 thoughts.

PulseOx is about the hemeglobin in whole blood in the periphery. You administer O2 based on signs and symptoms, not on a measurement. A doula should recognize the importance of using real signs over indirect pure measurements. Pulse ox says nothing about true oxygenation of the baby. You can't read 100% and ignore everything else.

Breathing: we are specifically taught NOT to let the mom hold her breath during contractions. That bearing down while holding your breath is absolutely wrong. It's also taught this way in prepared childbirth classes. I know it used to be taught that you should hold your breath and bear down, but I think it's pretty universal that it isn't anymore.

[mitchsmom]

...Breathing: we are specifically taught NOT to let the mom hold her breath during contractions. That bearing down while holding your breath is absolutely wrong. It's also taught this way in prepared childbirth classes. I know it used to be taught that you should hold your breath and bear down, but I think it's pretty universal that it isn't anymore.

Not where I'm at... they have all the moms do it that I've seen... "take a great big breath and count to 10!... 1, 2, 3, 4... ok do it again, big breath..." That was both in my regular OB rotation in another town and here in my town now in my preceptorship. Not saying it's right, just what I'm seeing.

[SmilingBluEyes]

the whole breathing thing while pushing ---so controversial. I love natural labor----never have to tell a woman WHAT to do or HOW. It just "comes"......unfortunately w/dense epidurals in so many cases, we are left w/few choices. The one I choose almost every time, is to allow a baby to "labor down" as low as possible before ANY pushing begins. Its good for mom and baby, alike.