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

[BonnieSc]

But how is pushing while holding breath EVER a good choice? This is also what's commonly used at my hospital. I was surprised, because I, too, thought this practice was archaic.

[tntrn, ASN, RN]

But how is pushing while holding breath EVER a good choice? This is also what's commonly used at my hospital. I was surprised, because I, too, thought this practice was archaic.

I wonder how you push without holding your breath? For many years now, we've used the analogy of pushing as if you were constipated and you surely don't breathe when you push like that.

In the perfect world all the OB's would stay away so that the epiduralized patients could labor down. In our place they aren't and are too impatient, so it can become a race or a contest of wills to get that baby down there (by pushing and not laboring down) before it gets decided to take another route. That is a sad fact, but a fact, nonetheless.

[NoMoreStudying]

I wonder how you push without holding your breath? For many years now, we've used the analogy of pushing as if you were constipated and you surely don't breathe when you push like that..

I didn't realize people still taught to push like a BM. I learned that you breathe or pant through the push, even in a prepared childbirth class taught by the hospital. Basically, breathing while pushing helps you to use the right muscles, rather than your rectum.

[SmilingBluEyes]

Like I said, epidural anesthesia has changed things.....alot. If a woman is without anesthesia, she needs little to no coaching "how" to push and breathe----it comes so naturally. With epidurals, things are very, very different and to make progress, some coaching and pushing (and yes for some we do count) is definately needed in many cases. That is why laboring down is so valuable. Saves the mom and baby from a LOT of "purple pushing" that would otherwise be used if baby were still high up at the outset.

[SmilingBluEyes]

Here is an excellent resource for anyone, particularly the author of this post:

The Labor Progress Handbook by Penny Simkin.

I highly recommend it.

[futureTMA]

mitchsmom, when I mentioned that she must be looking at research, I meant that only for that post and not the whole article.

Deb has spoken :) No more third person. I should tell you that that was my idea and obvious doing to try to carry out the discussion, though what was being talked about is beyond me. Basically, I don't have the knowledge to rebut what was being said so I quoted her with her permission.

I agree with Deb on pushing/breathing.

BTW, I'm sure she owns that book.

[BonnieSc]

Still not seeing any reason why you have to hold your breath to push. I think exhale pushing is so much easier and more comfortable, and it's also my understanding that it makes a vagal response less likely.

[tntrn, ASN, RN]

This is what I was taught, as a laboring mom, and as a nurse: if you exhale before you push, it's like trying to swim a lap without having any oxygen in the tank. Now to me, that makes perfect sense, having swam a lap or two, and it seems to make sense to laboring moms too. It's what we do where I work mostly...but there's always more than one way to accomplish a goal.

[BabyRN2Be]

I haven't been reading for a day and I just wanted to mention something. I am a little bit bothered that my comments about Stephanie were taken off this board. I do stand by what I say, but there is potential for things being taken out of context.

As Deb says, if Stephanie would like to register and participate in this forum, this is up to her. Although this is not a private forum, I would appreciate it if my statements about anything here stay at allnurses.com.

Conversations by third party are not a good idea. I hope that the OP does not feel bad by what I'm saying here. It would have been good if we had seen the entire transcript of what the OP had sent to Stephanie along with Stephanie's answers. I'm sorry, but this really bothers me.

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

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.

I've never heard that not breathing while pushing and counting to ten was archaic. We do it here.

However, not all the time. As Deb said, with natural births the women just seem to know what to do and I don't interfere with that. Some nurses do - and tell them to count to ten, etc.

With an epidural though -things change.

I don't see how a person can push and exhale . . . .

Kind of funny, I'm imaging all of us sitting at our computers trying to push w/o breathing . . . .

steph

[rpbear]

Kind of funny, I'm imaging all of us sitting at our computers trying to push w/o breathing . . . .

steph

:roll That is exactly what I was doing!!!!

[rpbear]

Although I don't agree with a lot of what Stephanie is saying I think this is a discussion that needs to be had between Doula's and RN's so that we can work together in a way that supports our pt's.

Each time I have a pt with a either a birth plan or a doula (or both) I sit down with them at the begining of labor (if possible) and go over things with them. I point out things on the birth plan that may need to be altered in case of an emergency. I sit down with the doula and pt and ask them what their expectations are of labor and delivery. This is a small step to make my pt, the family and the doula feel at ease with me. If I know what they are expecting and they know what to expect from me then things go wonderfully and they have a sense of trust in me. After all they just met me and now I am intrusted to help in one of the most important days in thier lives. It only takes a few minutes, but it can make or break your day.