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.
Does epidural analgesia increase rate of cesarean section?
Michael C. Klein, MD, CCFP, FAAP, FCFP
Conclusion
Contrary to the conclusion of the Cochrane meta-analysis of EA compared with narcotic analgesia, EA given before the active phase of labour more than doubles the probability of receiving a CS. If given in the active phase of labour, EA does not increase rates of CS. Meta-analysis can be helpful and timesaving for busy practitioners, but we need to be vigilant about which studies get into the meta-analyses and ask ourselves if they make clinical sense. And, unfortunately, we need to continue to read the individual studies that make up meta-analyses--especially if they are likely to actually change practice--to determine whether study conditions represent our clinical reality.
Best Pract Res Clin Anaesthesiol. 2005 Mar;19(1):1-16.
Labor epidurals and outcome.
Gaiser RR.
SourceDepartment of Anesthesia, Pharmacology, Obstetrics and Gynaecology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA. [email protected]
Abstract
The use of epidural analgesia for labor continues to increase dramatically. It has been suggested that epidural analgesia increases the risk of cesarean section, operative lady partsl delivery, and prolonged labor. These issues have been extensively investigated. The use of epidural analgesia does not increase the risk of cesarean section. It may affect the incidence of forceps delivery, but it depends on the medications used. Epidural analgesia does prolong labor, although the clinical significance of this prolongation has not been shown.
My words in bold: Another thing to consider is that women who have epidurals containing Fentanyl are more likely to have breastfeeding difficulties or failure, something that most anesthesiologists (and OBs) don't consider, as this is not something that directly affects them in the immediate. They don't see the longterm results of epidural use as it affects the infant, and the maternal/child bond of breastfeeding.
Int Breastfeed J. 2006; 1: 24.
Published online 2006 December 11. doi: 10.1186/1746-4358-1-24 PMCID: PMC1702531
Intrapartum epidural analgesia and breastfeeding: a prospective cohort study
Siranda Torvaldsen,1,2 Christine L Roberts,2 Judy M Simpson,3 Jane F Thompson,4 and David A Ellwood5
Abstract
Background
Anecdotal reports suggest that the addition of fentanyl (an opioid) to epidural analgesia for women during childbirth results in difficulty establishing breastfeeding. The aim of this paper is to determine any association between epidural analgesia and 1) breastfeeding in the first week postpartum and 2) breastfeeding cessation during the first 24 weeks postpartum.
Methods
A prospective cohort study of 1280 women aged ≥ 16 years, who gave birth to a single live infant in the Australian Capital Territory in 1997 was conducted. Women completed questionnaires at weeks 1, 8, 16 and 24 postpartum. Breastfeeding information was collected in each of the four surveys and women were categorised as either fully breastfeeding, partially breastfeeding or not breastfeeding at all. Women who had stopped breastfeeding since the previous survey were asked when they stopped.
Results
In the first week postpartum, 93% of women were either fully or partially breastfeeding their baby and 60% were continuing to breastfeed at 24 weeks. Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week (p
Conclusion
Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. Although this relationship may not be causal, it is important that women at higher risk of breastfeeding cessation are provided with adequate breastfeeding assistance and support.
The conclusion negates any real relationship. You would need two similar groups to show that epidurals have any effect on breastfeeding, which this study does not have (similar socioeconomic status/educational status etc).
Specializes in Nurse Leader specializing in Labor & Delivery.
With good labor support, you can passively descend without an epidural. I know, I did it. For SIX HOURS.
My first post was debating the fact that the first three articles you posted did not address your argument. They simply didn't. I'm not sure why you posted them. See my later post for articles.
And all research I have found, including the Cochrane review did find that giving an epidural before active labor does in fact double the risk of surgical delivery.
Don't get an epidural because it will inhibit your ability to breastfeed.
Pregnant women, harangued by a recent government campaign on breastfeeding and subject to endless worrisome news stories about how their activity and choices will affect those of their babies, have something new to worry about: A recent Australian study claims to have found an unusual side of effect of having an epidural - more trouble breast feeding.
Or did it? Dig into the data and there is surprisingly little evidence to support the theory that epidurals actually cause difficulty breastfeeding.
The study, published in the International Breastfeeding Journal was conducted by surveying about 1200 women on whether they had an epidural or not, whether they breastfed in the first few days after birth, and whether they continued to breastfeed their babies for 24 weeks after birth.
The authors found that women who had an epidural were more likely to have problems breastfeeding in the first few days, and less likely to breastfeed their babies for the full 24 weeks. Therefore, those who had an epidural were less likely to breastfeed.
An important principle in making comparisons between two groups (in this case, those who had an epidural and those who didn't) is that the two groups should be comparable. In other words, except for whether they chose to have an epidural or not, the two groups of women should statistically look pretty similar. This means they should have similar income, age, race, educational level, disposition toward breastfeeding, and similar birth experiences aside from the epidural.
But among the women in this study who had epidurals, 41 percent had cesarean sections (with anesthesia consisting of an epidural) and an additional 31 percent had births assisted with instruments. This compares with zero C-sections and two percent instrumental births among women who had no anesthesia. The two groups of women clearly had extremely different birth experiences.
This suggests that the women who didn't breast feed may have been dissuaded from doing so due to complications from surgery or higher exhaustion or pain level postpartum. Epidurals may have had nothing to do with it. It is possible that c-sections lead to problems breastfeeding, rather than epidurals.
Only 28 percent of the women who had an epidural also had lady partsl births without instruments. One might ask if those women also experienced more trouble breastfeeding than the women who didn't have an epidural. And when these two groups were compared, the authors actually found that there was no statistically significant correlation between having an epidural and partially breastfeeding (compared to exclusively breastfeeding). In other words, among women who had lady partsl births, women who had epidurals and those who didn't were as likely to only partially breastfeed as they were to exclusively breastfeed.
However, there was a correlation between using an epidural and having trouble breast feeding, even among the women who had lady partsl births. This suggests to the authors that there could be a pharmacological reason that some women have trouble establishing breastfeeding.
Even so, we should still be cautious in concluding that epidurals cause trouble. There are several obvious and rather subjective factors that also compromise any relationship between the epidural and breastfeeding. These variables might influence both breastfeeding and epidural use; without controlling for them, we should be very suspicious of any purported link. They include:
Attitude toward medical intervention. Women who are averse to using epidurals and prefer un-medicated births may also be averse to using formula instead of breast milk. This would easily explain why women who have epidurals are less likely to breastfeed.
Tolerance for pain or discomfort. Women with a higher tolerance for pain may both be less likely to request an epidural, and also more likely to breastfeed (which is known to be uncomfortable at the beginning for many women).
Exhaustion level from childbirth. Some women may get an epidural out of sheer exhaustion from labor. These same women may begin the process of caring for an infant more exhausted than women who had easier births, and find themselves less able to maintain or establish breastfeeding.
These factors may or may not play a role in why it is that some women have more success at breastfeeding than others. But without accounting for these rather obvious and potentially influential factors, it's simply cruel to suggest that accepting pain relief by an epidural will cause breastfeeding problems.
With good labor support, you can passively descend without an epidural. I know, I did it. For SIX HOURS.
My first post was debating the fact that the first three articles you posted did not address your argument. They simply didn't. I'm not sure why you posted them. See my later post for articles.
And all research I have found, including the Cochrane review did find that giving an epidural before active labor does in fact double the risk of surgical delivery.
Most patients cannot or will not do passive descent without analgesia. Your own experience does not equate to what most patients will tolerate or want to tolerate.
You need to do a Pubmed search, and look for randomized controlled trials or large retrospective studies.
Most patients cannot or will not do passive descent without analgesia. Your own experience does not equate to what most patients will tolerate or want to tolerate.
actually, if we want to speak globally, most women birth without analgesia. Analgesia in labor is a modern technology and is seen mostly in developed countries. Even then, the US uses this at a rate far higher rate than the rest of the developed world, where women still typically give birth without medical intervention.
Specializes in Nurse Leader specializing in Labor & Delivery.
Most patients cannot or will not do passive descent without analgesia.
Most patients don't have good labor support. That's where a good doula comes in. A good doula empowers a woman, gives her the tools to manage labor without drugs, which is usually/often what the woman's stated goal is.
Yay, did I just bring the thread full circle?
In answer to the OP, I LOVE a good doula. Makes my job so much easier. As a natural birther, I totally respect and understand the desire a woman might have to go naturally, and while I have the tools to help her, I don't always have the time. Especially if I have two labor patients. So a consider a good doula to be an extension of the labor support that I WANT to be able to offer to my patients, but often cannot. With a good doula, I can leave the room, knowing that my patient is in good hands and that she's doing whatever she can to help my patient.
Sadly, I've worked with bad doulas, who grossly overstep the bounds of labor support and health professional. I truly believe that these women poison the minds of the couples who come in, and set them up to be on the defensive and have an us vs. them attitude towards all healthcare staff. These same doulas also set up a very unrealistic expectation of the midwives. No, this is not going to be "a homebirth in the hospital." The midwives still do have to adhere to hospital policy regarding fetal monitoring (even as liberal as it is). If you have a BP of 150/100 and your uric acid and LDH are sky-high, the midwife is NOT going to smille and say "it's okay, women have been doing this for millenia, you'll be fine" and I certainly don't appreciate when YOU say that to the patient either.
actually, if we want to speak globally, most women birth without analgesia. Analgesia in labor is a modern technology and is seen mostly in developed countries. Even then, the US uses this at a rate far higher rate than the rest of the developed world, where women still typically give birth without medical intervention.
I totally agree. Do you want to compare adverse outcomes in those countries to ours?
I totally agree. Do you want to compare adverse outcomes in those countries to ours?
only if we are comparing birth and outcomes in developed countries. Then its more apples to apples, or as close as we can get.
and while I'd love to pull up even more articles, football starts here soon :-P But going completely off the top of my head of research I have read over the years is that the rest of the developed world has a much lower rate of maternal and infant morbidity and mortality than the U.S. They also have a much lower rate of medical intervention and birth happens by and large outside the hospital and/or with midwives with minimal to none medical intervention. OB typically attend the high risk births only (and this is where you see your analgesia and instrumental and surgical births). I mean if we want to logically think about this.....I think its safe to conclude that the more medicalized birth is, the riskier it is, and the greater morbidity and mortality.
A Randomized Control Trial of Continuous Support in Labor by a Lay Doula
Della A. Campbell, Marian F. Lake, Michele Falk, Jeffery R. Backstrand
Results: Significantly shorter length of labor in the doula group, greater cervical dilation at the time of epidural anesthesia, and higher Apgar scores at both 1 and 5 minutes. Differences did not reach statistical significance in type of analgesia/anesthesia or cesarean delivery despite a trend toward lower cesarean delivery rates in the doula group.
Conclusion: Providing low-income pregnant women with the option to choose a female friend who has received lay doula training and will act as doula during labor, along with other family members, shortens the labor process
J Dev Behav Pediatr. 2003;24:195-198
Benefits of a Doula Present at the Birth of a ChildMartian T. Stein, MDhttp://pediatrics.aappublications.org/content/114/Supplement_6/1488.full
some excerpts from the article:
"a result, an RCT of healthy women, each of whom was expecting to be supported by her male partner, was conducted. All could have family members present. A cesarean delivery was required by 22.5% of the women who were accompanied only by a male partner compared with 14.2% of those supported by both the father and a doula. This study showed the value of doula support for all mothers whether laboring alone or with a partner. The doula does not displace the father but supports him, shows him how he can be helpful, and relieves much of his anxiety."
"There were favorable effects of doula support on the subsequent psychological health of the women and infants. At 6 weeks there were impressive postpartum behavioral differences: a significantly greater proportion of doula-group women were breastfeeding (51% compared with 29%), and the doula-group women were significantly less anxious, had lower scores on a test of depression, and had higher levels of self-esteem. These maternal qualities would be favorable for the development of the infants."
Obstetrics & Gynecology, Vol 88(4), October 1996, Pages 739-744
Continuous labor support from labor attendant for primiparous women: A meta-analysis
Jun Zhang MB, PhD, James W. Bernasko MB, ChB, Etel Levbovich, Marianne Fahs PhD, Maureen C. Hatch PhDData Extraction and Synthesis Meta-analysis of four studies conducted among young, low-income, primiparous women who gave birth on a busy labor floor in the absence of a companion suggested that continuous labor support by a labor attendant shortens the duration of labor by 2.8 hours (95% confidence interval [CI] 2.2-3.4), doubles spontaneous lady partsl birth(relative risk [RR] 2.01, 95% CI 1.5-2.7) and halves the frequency of oxytocin use (RR 0.44, 95% CI 0.4-0.7), forceps use (RR 0.46, 95% CI 0.3-0.7),and cesarean delivery rate (RR 0.54, 95% CI 0.4-0.7). Women with labor support also reported higher satisfaction and a better postpartum course.
Conclusion
Labor support may have important positive effects on obstetric outcomes among young, disadvantaged women. Further studies on benefit relative to cost are needed before a broad-scale program is advocated.
Am J Obstet Gynecol 1999;180:1054-9
A comparison of intermittent and continuous support during labor: A meta-analysis
Kathryn D. Scott DrPH, Gale Berkowitz DrPH, Marshal Klaus MD
Abstract
Our goal was to contrast the influence of intermittent and continuous support provided by doulas during labor and delivery on 5 childbirth outcomes. Data were aggregated across 11 clinical trials by means of meta-analytic techniques. Continuous support, when compared with no doula support, was significantly associated with shorter labors (weighted mean difference -1.64 hours, 95% confidence interval -2.3 to -.96) and decreased need for the use of any analgesia (odds ratio .64, 95% confidence interval .49 to .85), oxytocin (odds ratio .29, 95% confidence interval .20 to .40), forceps (odds ratio .43, 95% confidence interval .28 to .65), and cesarean sections (odds ratio .49, 95% confidence interval .37 to .65). Intermittent support was not significantly associated with any of the outcomes. Odds ratios differed between the 2 groups of studies for each outcome. Continuous support appears to have a greater beneficial impact on the 5 outcomes than intermittent support. Future clinical trials, however, will need to control for possible confounding influences. Implications for labor management are discussed.
Also worth mentioning is that ACOG recently admitted that only a third of their recommendations are based on good and consistent scientific evidence.
And I know that ancedotal evidence can be taken with a grain of salt, but I've personally seen how epidural anesthesia prolongs the pushing stage of labor, how during this it can tire a woman out immensely, thus making the likelihood that she is going to have an instrumental delivery or even into OR a very real possibility.
Here are some studies supporting what I've personally witnessed:
Can Fam Physician. 2006 April 10; 52(4): 419-421
Does epidural analgesia increase rate of cesarean section?
Michael C. Klein, MD, CCFP, FAAP, FCFP
from their conclusion section: "EA given before the active phase of labour more than doubles the probability of receiving a CS."
Rates of caesarean section and instrumental lady partsl delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review
E H C Liu, A T H Sia
BMJ 328:1410 doi: 10.1136/bmj.38097.590810.7C (Published 28 May 2004)
Data Synthesis Seven trials fulfilled the inclusion criteria for meta-analysis. Epidural analgesia does not seem to be associated with an increased risk of caesarean section (odds ratio 1.03, 95% confidence interval 0.71 to 1.48) but may be associated with an increased risk of instrumental lady partsl delivery (2.11, 0.95 to 4.65). Epidural analgesia was associated with a longer second stage of labour (weighted mean difference 15.2 minutes, 2.1 to 28.2 minutes). More women randomised to receive epidural analgesia had adequate pain relief, with fewer changing to parenteral opioids than vice versa (odds ratio 0.1, 0.05 to 0.22).
ConclusionsEpidural analgesia using low concentration infusions of bupivacaine is unlikely to increase the risk of caesarean section but may increase the risk of instrumental lady partsl delivery. Although women receiving epidural analgesia had a longer second stage of labour, they had better pain relief.
Bottom line is that doulas can help mother's in labor. To state otherwise would be false. Women since the dawn of time have had their births attended by other women (and its only been in recent history have men attended and/or supported mom during birth) and the concept of having a doula is not a new one.
Additionally, epidural anesthesia does come with its own set of risks. There are many benefits to EA as well, some of which you wtbcrna, have pointed out. I also think to deny the many benefits of EA would also be a disservice to women and thats not my intention at all. However, we must properly educate women about the risks and benefits, and I believe that that needs to come well before she is in labor. I think the onus for providing true informed consent ultimately lies with the providers (OB/Gyn or midwife....with the anesthesiologist or CRNA reiterating these prior to performing the procedure), but women also need to properly educate themselves too and seek the answer to these very important questions. This dialogue and planning for birth needs to start early in the pregnancy.
I totally agree with you that education should start early in pregnancy. I don't doubt there is a benefit to having someone dedicated to the mother giving support throughout labor. Where I disagreed is having doulas explain the risks an benefits of medical interventions on that part will just have to agree to disagree.
wtbcrna, MSN, DNP, CRNA
5,128 Posts
The conclusion negates any real relationship. You would need two similar groups to show that epidurals have any effect on breastfeeding, which this study does not have (similar socioeconomic status/educational status etc).