Doulas?

SmilingBluEyes · May 27, 2005

we have had doulas; most WONDERFUL and very helpful. A few can be pushy ---but like nurses or doctors, you have good and not-so-good. Generally, I consider them a great resource and so do the families who hire them.

SheaTab · May 28, 2005

I love them as well. Honestly, they are a big help with a natural patient because without one, the nurse typically supports the patient to an equal or even greater degree than the SO. Everyone know's at my hospital to give me the natural patients because I love them. However... one must remember that the nurse must continue to document, document, document on that blasted flowsheet regardless of how busy she is with the patient. So, with a natural patient, it helps to have a little assistance. That being said... all nurses are different. The majority of the nurses at my hospital would prefer to mop floors than care for a natural patient and especially one with a doula. We are a very high-intervention facility. And of course, with the patient having an extra person there to advocate for her needs, it makes it hard for the docs and nurses to impose unnecessary interventions on them. Also... there are some pushy doulas. BUT... I think, with regard to my facility, the doulas have encountered a lot of resistance to their care and perhaps come in on the defense. Maybe expecting that they will not be welcome. I love them though. Good ones are very well-versed in caring for the woman in labor and it really does make my job easier. However, there are those doulas that seek to alienate the nurse and physician completely! I have seen them ask the nurse to repeatedly leave the room so that they can "discuss things." Perhaps they forget that nurses are good sources of information and that we are patient advocates by trade as well. It just makes for a very uncomfortable experience when this sort of thing happens. At my facility, the majority of our nurses roll their eyes when they see a birth plan or a doula coming. Sad, but true. I'm glad this is not the case in all areas. Women deserve to birth their babies in any way they see fit: with or without epidural, sitting, laying, squatting, whatever!. We should help more mom's birth their babies as opposed to delivering so many of them at my hospital.

Dayray, RN · May 28, 2005

I have worked with some fantastic doulas. They know there area is supporting and advocating for the patient.

However I have worked with many, many terrible doula's. Many doulas compete with you for the patient's attention. Sometimes they talk over you when you are explaining things.

I have encountered several different types of doulas:

1 The doula that likes supporting women and is also interested in the birthing process. This is the good kind because their main goal is to support the patient. Seeing and being part of the birthing process is a secondary part of why they want to be there.

2 Want to be nurse - these doulas really want your job so they try to tell you how to do it even though they have never been to nursing school and probably wouldn't make it threw.

3 The lookie lou - this doula loves the labor process and will ignore the patient's needs but want to watch all interventions and will ask more questions then the patient. I had one in a C/S the other day that positioned herself away from the patient so she could see around the drape and watch the c/s. This was really sad because the father wasn't there and the patient only had the CRNA with her behind the drape.

4 Doula with an agenda - these are the people that believe that birth should fit into a very narrow ideal. Generally that ideal is 0 intervention. They are there to make sure that the patient doesn't accept interventions and they will use any method to reach that goal. I have seen them shame patient's that ask for pain meds and even have had a few leave because their patient took an epidermal. I have had them accuse me of lieing and argue with doctors. I've also caught them adjusting pitocin. This is the worst kind of doula because they are not there to support the patient just to enforce their agenda.

After some bad incidences I have learned how to deal with doulas. I tend to give them the benefit of the doubt and assume they are good until they prove otherwise.

Still I let them know that the patient is my only concern and that I'm not there to take care of them or cater to their agenda. When the doula asks a question I direct my answer to the patient. If the doula tries to talk over me I keep on talking. If they over step their bounds (turn down pitocin or start a conflict with staff) I take them outside and raise my voice look them strait in the eye and tell them that I will have them removed if they do one more thing outside of there scope.

Although it probably sounds like it, I'm not anti doula. I actually love it when they support the patient. Sometimes I feel redundant but most of the time I like that I have some help and that the patient gets good support.

SmilingBluEyes · May 29, 2005

OMG DAY RAY IS BACK

I was just thinking aboutyou today!!!!!!!!!!!! HOW ARE YA BUDDY???

chuckc, BSN, RN · May 29, 2005

Oh my, I am a doula, and now am in nursing school. I have seen the "baad" doulas! there was one that worked in an OB/GYN office I worked, she would answer the phone, give advice at will, BAD ADVICE! I called her on it one day, she told a 13 week preg woman not to worry about left side abdominal pain, prob just ligament pain! I told her she was giving medical advice, not qualified, let OB know, it was his day off, he called pt and had her come in for exam. Fortunately, she was fine. This woman was scary! And yes, she was dismissed!

FrumDoula · May 29, 2005

Speaking as a doula, I can say that I've also seen some great doulas and some doulas that I wouldn't hire if my life depended on it.

I've rarely encountered a nurse who wasn't helpful and cool to me. In fact, I've had some nurses who were incredibly grateful for my presence and learn stuff from me that they didn't know. Their willingness to learn from a doula was really awesome. As much as I believe that our obstetric and hospital system generally shortchanges women, many nurses I've met were great to work with.

Docs run the gamut. A lot of it depends on the attitude you strike when you go in. Some of them like/love us, some hate us.

We tend to meet at least 2-3 times with a client, in her home, so we have a good idea of her hopes and desires for the birth. If I have a client who wants a natural birth, yet she's checking herself into a highly interventive hospital, I try and make her aware that hospital procedure and policy is a powerful indicator of what to expect. Realistic expectations are important as well. I also let her know that she can refuse interventions she's not comfortable with, as long as she's willing to take responsibility for the consequences. Heck, I tell her she has to take responsibility for the interventions, too!!! I'm sick of hearing about OB clients who take no responsibility to educate themselves, then sue because things weren't perfect. Pfeh.

The last birth I did up here in San Francisco was pretty cool. All the nurses were nice, with the exception of one real genius who said, upon entering the room and seeing my client pushing in an all-fours position, said "What's she doing?" This was, of course, accompanied by the I-just-sucked-a-sour-lemon look. Thankfully, my client didn't see her face. But the rest of the nurses were very helpful.

The fact of the matter is that the presence of a doula can make a real difference in outcomes. Less med requests, fewer epidurals, healthier babies, healthier moms, etc. It's been demonstrated in study after study. In fact, there was a study in Florida on doulas that was halted by the nurses involved in the study. Why? Because upon seeing the positive benefits of the doula to the mom, they felt it was unethical to keep women in the control group from having them! So even if doulas catch some flak, or a nurse doesn't particularly like our presence, we try to also remember that our work makes a very substantial, long term difference to the memory and health of that lady and her baby.

Cheers,

Alison

Dayray, RN · May 29, 2005

It's funny how the universe works. 11 hours after responding to this post I began an experience with a doula that ranks among my top 5 worst doula nights.

From the get go the doula would talk over me and give directions or explanations of medical procedures. I tend to be laid back so even though I didn't appreciate it I just listened and only corrected her if instructions were counter productive.

The night took a turn for the worst when I was explaining that we might need to start pit in an hour if labor hadn't progressed. This was a tough situation because the patent wanted natural childbirth but was GBS + and questionably had been ruptured for 24 hours. The doula started to talk over me and explain pitocin so I just let her until she told the patient that she could tell me not to turn up the pitocin if the contractions were uncomfortable. When I gently corrected her and explained that I would need to turn up the pit based on her labor pattern and dilation the doula acted shocked as though I were cruel.

The straw that broke the camels back came after the patient had gotten an epidural ...gotten to complete and was pushing. I started giving instructions and the doula again started talking over me. To boot they were really bad instructions and the pushing was all messed up the poor patient didn't know who to listen too.

I took the doula outside and was meaner then I ever like to be. I was very very angry and kind of let her have it.

After the delivery the doula asked to speak to the charge nurse and I. I think things got worked out but I still resent being pushed as far as I was.

It's not okay for doulas to make recommendations on pitocin or to push with the patient I mean both of those things greatly relay on assessment and that's the RN's role.

healingheart · May 31, 2005

Do you not agree that the patient has the right to refuse pitocin? Of course after 24 hours of ruptured membranes there is an obvious risk of infection. However, if the baby is doing ok, what is the harm in refusing pitocin? When does she lose her right to choose?

FrumDoula · May 31, 2005

It's funny how the universe works. 11 hours after responding to this post I began an experience with a doula that ranks among my top 5 worst doula nights.
The straw that broke the camels back came after the patient had gotten an epidural ...gotten to complete and was pushing. I started giving instructions and the doula again started talking over me. To boot they were really bad instructions and the pushing was all messed up the poor patient didn't know who to listen too.
I took the doula outside and was meaner then I ever like to be. I was very very angry and kind of let her have it.
After the delivery the doula asked to speak to the charge nurse and I. I think things got worked out but I still resent being pushed as far as I was.
It's not okay for doulas to make recommendations on pitocin or to push with the patient I mean both of those things greatly relay on assessment and that's the RN's role.

I'm sorry it was such a frustrating experience for you with this doula. I'm grateful that the client wasn't part of the argument, either - it's not the best thing to help encourage a healthy labor and birth!

I'm curious - what was the bad pushing advice that she gave? In both my Lamaze educator and doula training, we learn a lot about pushing positions and techniques to help our clients push more effectively, both with and without epidurals. I have never been told, either by doulas, educators, or the nurses themselves, that it is strictly an RN issue.

Hopefully, this situation will be worked out amicably for both sides. It's hard when there's tension in the labor room.

Alison

Dayray, RN · May 31, 2005

Do you not agree that the patient has the right to refuse pitocin? Of course after 24 hours of ruptured membranes there is an obvious risk of infection. However, if the baby is doing ok, what is the harm in refusing pitocin? When does she lose her right to choose?

I am not sure how you turned this into an issue of a patient refusing pitocin or me forcing a woman to take pitocin. I certainly don't see anything in my post about someone not having rights to refuse pitocin.

In fact the doula didn't even question the use of pitocin. What she did do was express her own opinion on how pitocin should be used. No matter how many births the doula has been a part of or how many books she has read she is not qualified to make recommendations on how medication should be administered.

What I hear in your post is a hyper reflexive assumption that nurses force patients to do things that they don't want to. This attitude could not be further from the truth. I absolutely hate giving natural childbirth patients pit. During report people assumed I would take this patient because they know that I like natural labor. I really didn't want to take this one because I knew that the patient was going to end up on pitocin. I did take her because I knew that I could make the situation less difficult for her because I respect her wishes more then some of my coworkers.

You ask, "what is the harm in refusing pitocin?" Well let's review the situation.

6 hours after having a prostin suppository, 26 hours after rupture of membrains, 12 hours from her last meal and 36 hours from the last time she slept the patient had been walking using pressure points and nipple stem. She had been contracting for the last 5 hours and was breathing threw them and ratting her pain 7/10. Her contraction pattern was irregular but her pain level made me think that she might be changing her cervix (even though she wasn't acting like it).

I checked her cervix and it was exactly the same as the exam the previous nurse had reported to me. Because of her fatigue, pain and the fact that she is ruptured for an extended amount of time with GBS her chance for a positive birth experience via natural childbirth are fading and her risk of infection is climbing. She is not in labor the contractions are the result of irritation from either the prostin or bacteria and not changing her cervix. Her pain is high more because she is reaching exhaustion then because of the strength of her contractions. So this is what I told her.

"Dr. ___ has ordered pitocin and I think that we should use it. I want to make sure you understand that you don't have to do what we say. You should listen to what we have to say, ask questions and then make a decision. It's your body and your baby so you have to make the decision. For most women labor starts within 2 hours of rupture some women will go into labor in the following 24 hours. Your bag of water is a barrier to infection and once it is gone bacteria that lives in your lady parts can begin to grow in your uterus and cause an infection. Babies can get sick but usually they don't. More often mom gets sick this can be serious but because you are in a hospital and because we would give you antibiotics you would most likely only have flu like symptoms and some abdominal pain or might not notice anything. Eventually labor will start without pitocin but this will likely be due to bacteria. I hate to give natural patients pitocin but I think that we should. You are getting tired and the more tired you get the less positive your birth experience will be I'm also concerned about your risk of infection and I think that you have given labor a good chance to start on its own.

The patient said that she wanted to start pitocin and the doula didn't challenge that instead she proceeded to tell the patient how the medication would be managed and this was the point that she steeped over the line. I would have been less angry and less surprised if the doula had offered alternatives to pitocin (although we had exhausted them).

Now that I have explained the situation in depth I'll answer your question. A patient always has the right to refuse anything but in this case to refuse pitocin would have been bad. Well I support a patients right to make decisions even if they are bad I would have been sad if she had because she would be taking risks with her health and ruining any chance she had for a positive birth experience. At this point the patient was too tired to wait for labor to start on it's own much less endure unmediated labor. I didn't suggest an epidural but she asked for one and I was glad she did.

You may think that my opinion is biased or that my actions infringed on this patients personal freedoms. Sometimes I wrestle with this but it's my job to do the best I can for patient and help them be safe. Many times that job requires me to suggest things that are difficult for patients. In this case I was almost as concerned about the patients social and emotional health as for her physical health. Maybe I'm becoming more medicalized but I have looked into the eyes of patients who have gone threw 48 hour unmediated labor and seen terror and trauma. If my bias keeps that from happening then in glad I have it.

Many people are interested in childbirth and this had sparked a huge community of doulas and childbirth educators. I have email correspondence with many people in this community and have read many of the books that popularize it. There is validity to many of the idea's held by this community. Still too often this community portrays nurses and doctors as power hungry Gestapo like people who care nothing for patients wishes and only about money and power over others. Sadly there are some people that fit this description. However most healthcare professionals and I are far from this. Pitocin is a tool and I have spent allot of time learning how to use it. I use it to help people not to speed up their labor or to inflict pain on them.

As I said before I have friends in the doula/childbirth community but I find it silly that they point the finger at nurses as infringing on patients rights. If you do a bit of reading you will find that it was nurses who first sugested that pateints even had rights. Pateint advocacy is part of the nursing role. I take exception to being accused of ignoring a patients right to choose as I daily defend it and often at personal and professtionl risk. Ill sum up my response to your sugesstion in one word "Bah!"

Dayray, RN · May 31, 2005

I'm sorry it was such a frustrating experience for you with this doula. I'm grateful that the client wasn't part of the argument, either - it's not the best thing to help encourage a healthy labor and birth!
I'm curious - what was the bad pushing advice that she gave? In both my Lamaze educator and doula training, we learn a lot about pushing positions and techniques to help our clients push more effectively, both with and without epidurals. I have never been told, either by doulas, educators, or the nurses themselves, that it is strictly an RN issue.
Hopefully, this situation will be worked out amicably for both sides. It's hard when there's tension in the labor room.
Alison

Her advise was out of a book I guess I should clarify by saying that it wasn't so much bad as it was just not fit for the situation and different from what I do. The real problem was that she was giving conflicting information with me. This confused the patient and was counterproductive. I'm not sure how I would have handled the situation if she had told me she planned to instruct the patient. What she did do was wait until I was talking and then proceeded to talk over me in a louder voice then I was using. I am not a loud or aggressive person and I refuse to have a battle of wills in a patient room.

As far as pushing being a nursing role I suppose that could be seen from different perspectives and subject to opinion. I had thought that it was clearly a nursing role (for hospital births) but the doula later told me that nurses at my hospital had allowed her to handle pushing. So I guess it's more an opinion then a clear-cut fact. Ill share my opinion.

When I help a patient push I gage my instructions to the patient. At my hospital most patient with an epidural can feel pressure but cant feel the babies head descending. Most say that they can tell they are pushing but can't feel what they are pushing or if its doing anything (this can be frustrating for them). I help them by initially placing my fingers in the lady parts with slight pressure on the pelvic floor as a focal point. I also assess fetal decent from time to time and change my instructions based on that. A doula can't do either of those so that makes it hard for them to give specific instructions. To me this is assessment and that is not part of what I see as a doula's role. I suppose it would be less of an issue if the patient does not have an epidural but I still wouldn't like that because I am professionally and legally responsible for the instructions the doula is giving and the outcomes from it.

I have done allot of reading from both nursing and doula/childbirth educator literature and am also a certified child birth educator. I don't think that the information I received from these sources was nearly as valuable as the information I have assimilated from actually being an L&D nurse. This doula kept pointing out that she had been a doula for 4x as many years as I had been an RN yet she had only attended 300 or so births where I know that I would be well over 1000 most, of which I helped the patient push.

Recently a graduate student did a study on nurses and the percentage of their patents that had C/S for failure to descend after pushing. My percentage was the lowest. I also recently had a doctor tell me that she was amazed that my patient delivered lady partsly because her pelvis was narrow her baby OP and 8 pounds (in a 16 y/o primip). I'm not tooting my own horn but I have faith in my ability to help patents push.

It really comes down to weather or not I am willing to except responsibility for what the doula is doing and in this case I was not.