Doulas: love them or hate them.

[Sixxer]

I am trying to get a better understanding on why my co-workers hate doulas and I am pretty sure it comes down to control. There are 2 local hospitals with L&D and one welcomes doulas and mine hates doulas. The other hospital knows some doulas by name and greets them warmly. If a patient is sent for a section, the doula almost always accompanies the mother (along with the FOB or main support person) to the OR.

It's very different where I work. I hired a doula and sensed the hostility towards them at my hospital. My co-workers didn't know prior that I was going to have one there. I knew I had a strong possibility of a section and I wanted emotional support to avoid medication in hopes to avoid a c-section. I did end up with a section... because I work there my doula came to the OR with me. But, NEVER have I seen another doula go back there. My doula does not want to take patient delivering at my hospital anymore. She has been treated so poorly. I am now friends with a few doulas in the area and they all say the same thing about my hospital.

I took care of a woman with a doula a few months ago. I did not know this doula at all. I smiled at her, addressed her by name and when ambulating the mother, I accepted her assistance when she offered it. At one point I offered to get the mother and doula a water. She followed me out of the room and told me that no one at this hospital has even been this nice to her. I'm not surprised to hear her say this. The sad part is that I didn't give her special treatment, I just acknowledged her as a human being.

When I ask my fellow co-workers, they have said, "I just don't see the point of a doula/Why not just have your mother there?" (This is when I mention that studies have shown that doula support can increase your chances of an unmediated birth as well decrease your chances of c-section. I can give many more reasons for a doula vs. mother/sister/friend.) And they have told me that doulas give their patients medical advice and they don't like that. Or that doulas are pushy and always suggesting position changes or decreased monitoring.

One of my doula friend knows a charge nurse. We have all suggested having a "meet the doulas" day. This way the nurses can ask questions or even create boundaries on what is considered medical advise and maybe we can all work together without tension in the future. This ended up fizzling out. I know the only nurses who would come are the very few that like doulas. One of the other nurses confided in me that she was a doula prior to becoming an OB nurse, but she didn't want anyone else to know.

Thank you if you took the time to read all of this. I would love to hear some of your perspectives.

[wtbcrna, MSN, DNP, CRNA]

Look a little closer... for that organization to certify a doula it is the hours of instruction, attendance at childbirth classes, completion of a reading list, attendance at births with evaluations filled out by the provider, and a test.

The healthcare provider should be the one explaining the r/b/a to a patient, not the doula. The doula may help the patient decide based on the healthcare provider's information. A doula is generally more qualified than the average person to make those decisions, why wouldn't that be helpful?

I still disagree that a lay person with a few hours formal instruction who may have read a couple of books (I didn't see the list the first time) should be involved in explaining/helping a patient making any R/B/O decision. I did a search of the one of website informational material. http://www.dona.org/PDF/CIMSinduct-fact-sheet.pdf It is one-sided and only presents research that supports their viewpoint.

You should have a lot more formal training before discussing R/B/O of labor interventions with patients.

I think all the comfort and care that Doulas do for the mother/infant is fine. It is when they try to intervene in this aspect of care I disagree with.

[somedayCNM, CNM]

I still disagree that a lay person with a few hours formal instruction who may have read a couple of books (I didn't see the list the first time) should be involved in explaining/helping a patient making any R/B/O decision. I did a search of the one of website informational material. http://www.dona.org/PDF/CIMSinduct-fact-sheet.pdf It is one-sided and only presents research that supports their viewpoint.

You should have a lot more formal training before discussing R/B/O of labor interventions with patients.

I think all the comfort and care that Doulas do for the mother/infant is fine. It is when they try to intervene in this aspect of care I disagree with.

I see your point on the training and I'm sure if we're to see more doulas at the bedside during labor their profession is going to have to become more regulated. Let me tell you a true story that might explain a little better how a doula might "intervene" in the situation of an episiotomy: The doula and her client have reviewed the birth plan before labor and the client has stated that she wants to avoid an episiotomy. After two hours of pushing the client is exhausted. The ob says, "Ok, now I'm just going to make a little cut." The client, worn out and barely hearing the doctor, nods. The doula says to the client, "He's doing an episiotomy. Are you ok with that?." The client comes right around and says, "No!".

Here's what I see in this story:

1) It was the OB's responsibility to obtain explain the R/B/O of an episiotomy and obtain consent. He didn't. The nurse was also silent.

2) The doula didn't say, "she doesn't want an episiotomy". She helped the client clarify the decision to be made.

Doula's are coming to hospitals with patients because this happens: interventions they don't want, OBs doing procedures without obtaining adequate consent or fully explaining the R/B/O, and nurses failing to advocate for their patients. It's is our job to get this done, but when we don't, who could blame the doula for speaking up?

[melmarie23, MSN, RN]

I fail to see where medical training is absolutely necessary in order to be informed/knowledgeable of the R/B/O's of any intervention in labor and delivery. There is plenty of literature out there highlighting all of the above that serves to inform.

I think many have illustrated how there are good doulas and then not so good doulas. I think a good doula is one who remains abreast current literature and evidence based practice related to L&D, who can discuss these with her clients prior to the birth, and construct a plan with the mother so that she (the doula) can properly advocate for the mother when the time comes. Because lets be honest here...many MDs do a poor job of properly obtaining informed consent. Often times its just a piece of paper that they give to the patient to read and then sign without truly going over the R/B/Os. And while in the throes of labor, it isnt really the best time to be obtaining informed consent. It needs to be done prior, while the mother isnt vulnerable and in pain and about to embark upon one of the most emotional times in her life.

[kcparker]

I work as a doula, and I'd like to point out that one things a doula also does is help the mother (who has often hired her because she wants to labor without pain medication and avoid unnecessary interventions) rethink her options if labor is turning out to be more painful or complicated than she thought. One of our most important roles is to help the mother roll with it if it turns out that she does need pitocin/epidural/c-section.

It can be really disappointing and frightening to have a birth not turn out as you had hoped. Doulas typically have an established relationship with their clients, so there is a level of trust built up that might not be present with a nurse or doc. who just came on shift and the client has never seen before, and having the doula confirm for the mother, "No, you are not weak. You are not a failure. You didn't disappoint anybody. Sometimes things just don't go the way we plan, and you are making good decisions to keep you and baby healthy" can really help the mother be able to meet her baby with joy, no matter what the details of the birth.

Doulas don't make medical decisions or dispense medical advice, but we know how to read, ask questions, and translate medicalese into plain English when the medical staff is hustling in an emergency. The doula does everything she can to make sure the mother understands what is going on, that the mother plays an active role in deciding about her own plan of care, and the mother's preferences are honored to the extent that it is medically practicable.

And the R/B/O discussion isn't the sole purview of the care team. You KNOW that pretty much every intervention has at least one alternative. For example, an induction can be started with a synthetic prostaglandin (cytotec pill, cervadil on a tampon, or prepadil gel), the cervix can be further dilated with a foley balloon, laminaria, and/or pitocin (which can be given as a very low-dose drip overnight to prime the body for doing that work of labor in the morning) is started. If you just need a little augmentation, you can try nipple stimulation (or even a make-out session with the husband) to get the body's oxytocin going. Will a client necessarily get all these options from the provider's lips, along with a full R/B/O rundown (including relative cost and relative effectiveness) for each one? Will the provider take into account mother's preferences or just do whatever their usual procedure is?

If you are in doubt about the quality of literature that doulas read as part of certification, pick up a copy of Penny Simkin's book The Birth Partner for an example of the medical information we get even with 'basic training.' Plus, doulas, like nurses have to do continuing ed. We are supposed to keep up with the state of evidence, current recommendations, and best practices. ACOG itself just came out with a bulletin stating that only 1/3 of the recommendations in its own practice bulletins were Level A evidence-based, and many practices were either not supported by evidence or had no evidence to support or contradict. Here's the link to that: http://journals.lww.com/greenjournal/Fulltext/2011/09000/Scientific_Evidence_Underlying_the_American.3.aspx

Finally, while I can't speak for all doulas, I have made it my business to know the standard policies and procedures in place at the area hospitals so I can tell my clients, "If you are birthing at hospital X, you can expect these things. If you are at Y, expect this set of care protocols." They know what to expect, and the know the setting is a good match for the kind of labor/birth they want (or they are willing to work within whatever restrictions are in place at that location). It's not my job to pick the care setting that makes them the most comfortable, but it IS my job to work harmoniously with the nursing staff and doctors/midwives in whatever location my clients choose. Picking fights with the care team is counterproductive.

[beachyfe]

As a mother, I had both home and hospital births. I also worked for many years with a home birth service. As a nurse, I worked in an L&D where we had every type of birth - from "home-like" to very high risk. I supported whatever the mother wanted as long as it was within the bounds of safety. We had many lay midwives act as support persons when they brought in a mom who planned a home birth but something was going wrong and eventually doulas became popular and we had many of them too.

Doulas don't make medical decisions or dispense medical advice, but we know how to read, ask questions, and translate medicalese into plain English when the medical staff is hustling in an emergency. The doula does everything she can to make sure the mother understands what is going on, that the mother plays an active role in deciding about her own plan of care, and the mother's preferences are honored to the extent that it is medically practicable.

This is the ideal, but was not what usually happened when doulas came to our unit. Some were focused on just supporting the mom, but many seemed to want to "pick on" everything the nurse was doing. They acted very aggressive and pushy, trying to prove that they knew more than the doctors and nurses about what was best in the situation. The moms seemed sort of intimidated by them and didn't say much. That was sad.

If something happened where we felt unreassured that mom or baby were OK, the doulas usually questioned our judgement and argued about everything. This made it so hard to explain the situation to the parents and help keep them calm. I am very supportive of natural birthing, but the real purpose of childbirth is to end up with a healthy mom and baby - the "experience" is not the most important thing. So, if interventions are needed, there usually isn't time to have a long drawn out discussion but we tried to explain things clearly in layman's language in the time frame we had. I just found that the doulas were defensive and argumentative about 80% of the time. One of our local hospitals had such a bad experience with doulas that they banned them! Parents can still have support persons, but told ahead of time that they can't have a hired doula.

Finally, while I can't speak for all doulas, I have made it my business to know the standard policies and procedures in place at the area hospitals so I can tell my clients, "If you are birthing at hospital X, you can expect these things. If you are at Y, expect this set of care protocols." They know what to expect, and the know the setting is a good match for the kind of labor/birth they want (or they are willing to work within whatever restrictions are in place at that location). It's not my job to pick the care setting that makes them the most comfortable, but it IS my job to work harmoniously with the nursing staff and doctors/midwives in whatever location my clients choose. Picking fights with the care team is counterproductive.

I sure wish the doulas I worked with had done this homework and realized that we're all a team trying to help these parents have a healthy, happy baby. But most seemed like they arrived "ready for battle." It was like they saw this as a Doctor/Nurse vs. Patient/Doula fight. What they didn't realize is that we wanted that mom to have as wonderful a birth experience as possible. We were there to help keep she and baby safe. But everyone also has to realize that doctors and nurses have licenses and are mandated to practice according to the policies and procedures of the hospital. If a patient doesn't want to abide by that, then they should deliver somewhere else. But please, doulas, just support the mother and help her cope with labor without being adversarial. We all have the same goal - a safe delivery.

[PNCC2001]

Doula's are coming to hospitals with patients because this happens: interventions they don't want, OBs doing procedures without obtaining adequate consent or fully explaining the R/B/O, and nurses failing to advocate for their patients. It's is our job to get this done, but when we don't, who could blame the doula for speaking up?

This is a very valid point. I agree that there are bossy, aggressive, overbearing Doulas. However, I know from experience, I am also a Doula; that hospital medical staff rarely give fully in-formed consent that is required by law. I have heard many doctors minimize the potential side-effects of interventions, if they are brought up at all or so routinely do "standard procedures" and don't obtain informed consent. I try to remain as professional as possible in these situations. The mom has already been given the R/B/O's by me prior to delivery; but it is the OB/Midwife/Anethesiologist's obligation to do so.

In regard to training, Doulas are required to study the A&P of pregnancy, labor and delivery; risks and benefits and alternatives of interventions; comfort techniques, positioning that impedes or progresses labor; normal labor and delivery and potential complications in pregnancy and labor; medications, and much more. The training is only a weekend, but the studying is much more comprehensive. To assume that Doulas have no medical training is a fallacy. In the case of Certified Doulas, they are required to do continuing education and re-certify. Some certifying organizations have a more holistic, natural focus than do others, which accounts for some differences between Doulas. Some who appear to be Doulas, are actually Certified Monitrices or Midwife Assistants and under their SOP may do vitals, FHT's and pelivic checks. We are all trained to support the mother's wishes, regardless of what they are; but we also have an obligation to make sure that the mother has received full information, in order to be able to make decisions for herself and her baby. I am in support of medical interventions when they are needed, but not when they are done routinely. I am educated in evidence-based practice in Maternity Care and have a healthy mother and baby as my goal.

When I am attending a birth, I show respect for the hospital staff, I am not confrontational and assist them when I think it will be appreciated. In 10 years of being a Doula, I have never had a Doctor or Midwife appear that they did not want me there; in fact I have had several Doctors, Midwives and Nurses express gratitude to me for the assistance that I provided. I have only worked with one Nurse that seemed perturbed with my presence.

Many insurance companies now realize the value of Doulas attending births and are paying for Certified Doula services.:heartbeat

[wtbcrna, MSN, DNP, CRNA]

"Informed consent is a patient's right to be presented with sufficient information, by either the physician or their representative, to allow the patient to make an informed decision regarding whether or not to consent to a treatment or procedure. Patients generally are recognized as having the right to refuse medical care for any reason. Their reasons may include religious grounds as well as any other personal grounds they choose, even if you as physician consider their grounds to be frivolous or in poor judgment.

Informed consent must be obtained by a health care provider who is reasonably involved with the patient's care. A medical student therefore may not obtain consent, as they are not allowed to be responsible for patient care. The legal requirement to obtain informed consent rests with the attending physician. The attending physician may delegate his or her responsibility to obtain informed consent to another health care provider; however, he or she remains responsible and liable if appropriate consent is not obtained.

If informed consent is not obtained, the patient has the right to sue for medical malpractice. Informed consent is necessary any time the physician is going to either touch the patient or perform an invasive procedure. Informed consent may further be divided into two parts. These parts include Express consent and Implied consent.".

http://www.med-ed.virginia.edu/courses/rad/consent

Providers are not required to give a "full" informed consent. We are required to give patients enough information to make reasonable judgement on their own about whether the risks are worth the benefits of particular procedure or anesthetic.

I don't consider a Doula a healthcare provider or educated enough to explain risks and benefits to a patient.

[mollyaqua]

Ditto. My sentiments exactly. I'll try to do my own narrative later, but I've had very mixed interactions with doulas. Some good, some neutral and some I could have throttled.

[PNCC2001]

" Providers are not required to give a "full" informed consent. We are required to give patients enough information to make reasonable judgement on their own about whether the risks are worth the benefits of particular procedure or anesthetic.

I don't consider a Doula a healthcare provider or educated enough to explain risks and benefits to a patient.

I believe that I said that patients are not being given enough information to make reasonable judgements about their care for themselves and their babies.

Insurance companies consider Certified Doulas to be healthcare providers. The NPI Enumerator assigns an NPI (National Provider Number) to Certified Doulas and insurance companies pay for their services.:heartbeat

[wtbcrna, MSN, DNP, CRNA]

I believe that I said that patients are not being given enough information to make reasonable judgements about their care for themselves and their babies.

Insurance companies consider Certified Doulas to be healthcare providers. The NPI Enumerator assigns an NPI (National Provider Number) to Certified Doulas and insurance companies pay for their services.:heartbeat

Insurance companies recognize Doulas because they decrease/slow down intervention rates (epidurals, pain meds, etc.). It helps the insurance companies bottom line.

[PNCC2001]

Insurance companies recognize Doulas because they decrease/slow down intervention rates (epidurals, pain meds, etc.). It helps the insurance companies bottom line.

You're right. Doulas do decrease/slow down intervention rates (epidurals, pain meds, etc) which reduces health care costs and improves the health of moms and babies. I don't see anything wrong with that...?

Insurance companies are not the ones that determine who is considered a healthcare provider; it is the Federal HIPAA Regulations that do.

[wtbcrna, MSN, DNP, CRNA]

You're right. Doulas do decrease/slow down intervention rates (epidurals, pain meds, etc) which reduces health care costs and improves the health of moms and babies. I don't see anything wrong with that...?

Insurance companies are not the ones that determine who is considered a healthcare provider; it is the Federal HIPAA Regulations that do.

Really, I would like to see the research that shows that doulas improve health of moms and babies. Your making a big jump assuming that decreased intervention rates=better outcomes.

You will have to show me where HIPPA makes determinations on who is a healthcare provider and who isn't.