Doulas?

Zhlake · May 31, 2005

I am a labor nurse and I doula with my second labor. She was worth her weight in gold!!! I loved the support I got from her and would highly recommend a doula to anyone.

We worked together extensively during my pregnancy. She talked to me in length about my last labor and how I felt like that went. She also talked to me about comfort measures that I would like to try, and others that I wasn't interested in. We discussed the book "Birthing from within" together.

I have a very supportive husband, but the doula was just that added boost of support. I got to pick which labor nurse I wanted, so I let her know I was having a doula, and we got to talk about everyone's roles beforehand.

My doula told me that she would not discuss any procedures with any medical staff. If I had questions or wanted to discuss things with my doula, she would do that, but I had to be the one to talk to the medical staff.

healingheart · Jun 1, 2005

Dayray,

Thanks for your thorough response. You are right, I am hyper reflexive to the use of interventions in the hospital. I am a new graduate nurse with a year of doula experience and homebirth roots. Specifically I was responding to the word need in your sentence: "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." I appreciated the rest of your explanation and needed to hear more of the story before making any assumptions or accusations. I apologize for this. I know that I will learn a lot from the experienced nurses out there... unfortunately I have seen plenty who seem less than willing to support women in natural childbirth, and creating the positive birth experience despite the circumstances. My nature is not to do things because of tradition or policy, but to question whether it is the best way to do them for everyone involved. This will no doubt cause some conflict along my path. Communicating is the key.

Thanks again for explanation,

Hannah

Reddy,RN · Jun 2, 2005

It's funny how the universe works.

I, for one, am grateful that this topic and your most recent experience gave me a "you are there" look at a tough labor. I really appreciate the posts in this thread. And the way you wrote it Delray, I really did understand what was going on. Thanks.

I 've read a few chapters in my Maternity text now. I won't start clinical for a couple of weeks. So I'm really dangerous right now - I have only the tiniest little bit of knowledge.

So....when I saw the thread title I wondered if "Doulas" was a typo for "Douglas' cul-de-sac" [or pouch]. As a student I know I don't know, but I still try to figure things out. Sometimes I'm so wrong I just have to laugh. (I won't forget either term now.)

I did have to look up GBS but I was amazed that everything else was crystal clear. (For the benefit of other students who will eventually start their OB clinical, and you probably figured it out from the context, or retained more microbiology than I did, GBS is Group B Streptococcus.)

Thanks again. This was great.

SheaTab · Jun 3, 2005

Awesome on your low c-section rate for failure to descend!! Would you mind sharing with us some of your secrets. I am often frustrated when moms (esp. primips) can't even feel pressure to push and end up pushing for a couple hours or with forceps, vacuum or a section. I love to hear tricks of the trade. Do share. ;o)

SmilingBluEyes · Jun 3, 2005

For me, there are some things that come to mind that work:

Try not to get an epidural too early, if possible. That means, you want mom in active labor, with adequately strong contractions that are changing her cervix. I think women are getting epidurals too soon, and studies show this can impede progress!

When the epidural is going: Have mom change positions frequently (like a pancake, flipping around). From sitting up (really high, to faciliate gravity working for you)--- to left to right and back, keep her moving , particularly when she comes close to completely dilated. This may help baby "corkscrew" around to the right position to descend further----works well for persistently OP babies. And it's good for mom's circulation NOT to be in one position for hours, anyhow. The worst position for mom to labor is on her back----so get her off her back! She can push on her side, too. I have had moms lay left or right lateral, helping them hold up the leg and push this way. This works well to "unstuck" a baby who won't descend! Just get her off her back, if you can!

Let mom "labor down" in the epidural situation. Don't have her push at all til the baby is very low, if at all possible. This will save her potentially HOURS of working against the numbness of the epidural, trying to bring the baby down. If you move her enough and the contractions are adequate in strength, her uterus will bring the baby down by itself, really. Especially for primips, laboring down is the best way to go.

Often, the epidural's effectiveness/numbness wears off just a little as descent occurs---and those nerves are irritated and pressed with fetal descent. Ask the mom to tell you if she feels anything "different"----pressure, pain, vomiting, fullness in her rectum, etc. That MAY be her baby coming! Often increased complaints of pain during epidural drips signal progress, so be sure to check! I have had many a mom change quickly when put on her side-----and tell me "OH I FEEL SOMETHING WEIRD" (that something "weird" was the baby's head coming down).

Request the epidural rate be turned down if the patient is so numb she can't move or feel ANY thing, including pressure. It's nearly impossible to push when there is not even a sensation of pressure to work with----and the failure to push sufficiently and for baby to descend very high when so numb. Tell the anesthesiologist the situation, most are very willing to turn the rate down to enhance progression to delivery!

Plant those seeds of information early w/mom. Discuss how to push and what you will be doing before you do it. I will discuss pushing typically when mom is 7 or 8 cm, and then repeat the information when it's time. They often "absorb" what to do better, when you tell them sooner what they need to do to succeed.

HTH. :)

SheaTab · Jun 4, 2005

Great Info! Thanks.

Dayray, RN · Jun 5, 2005

Awesome on your low c-section rate for failure to descend!! Would you mind sharing with us some of your secrets. I am often frustrated when moms (esp. primips) can't even feel pressure to push and end up pushing for a couple hours or with forceps, vacuum or a section. I love to hear tricks of the trade. Do share. ;o)

I agree (as usual) with all the things Smiling said about pushing. I do a few other things in addition. I'm not really sure how much contributes to success and how much is just my style but it's hard to separate the two.

The way that I push with patients is rooted in my philosophy of labor. It might sound a bit corny and I hope it doesn't step on anyone's tows.

To me labor is a process that primarily brings a baby into the world but I also think that it kind of prepares moms (and to a smaller extent fathers) to be parents. I don't want to get too deeply metaphysical and I'm not a flowechild but I think we can agree that labor is as much psychological/social as physical.

Because I think this way, I try to emphasis that the patient is "delivering this baby" I also work really hard to make them feel that they are good at this and to pay attention to the cues their body is giving them. Before we start pushing I assess how much sensation they have I rarely turn down epidural because we have pretty good epidurals where I work but some patients have more feeling then others. I continually ask the patient what she is feeling and try to get her in tune with that. If they can feel pressure things go much easier.

I generally start out in lithotomy position with the patient pulling back on her knees and tucking her chin. I have her take a deep breath, hold it and then bear down, stop pushing, let the air out, take another breath and push again. I don't count unless they really want me to, I think it's better if they just hold the push until they run out of air. I try to get them to do 3 pushes per contraction but if they do better with 2 long ones or 4 short ones that works too. If they aren't pushing long enough or too long I tell them a few times "ok hold it a bit longer" or "let it go now" until they get a feel for it. Sometimes it takes them a while to get a feel for it but I want them to get "the feel" rather then just listening to me. I always start out with 2 fingers in the entrotus and put slight pressure on the rectum and tell them to push my fingers out. This also allows me to feel if the baby is moving with pushes.

Another thing I do is feel how the baby's head is angled in relation to the pelvic arch. I will adjust their bed to make the angle of the baby's head to the pelvic arch as close to a strait path as possible. Sometimes the angle changes several times so I might adjust the bed allot.

Another thing I do often is sideling pushes. You lay the patient on one side and have them pull back on 1 leg when they push and flip them to other side after 3- 5 contx. Side lying works well for asynclitic/OP babies but I also use it when the baby has stooped coming down. Sideling isn't so much about decent as it is about allowing the baby room to rotate and mold to the pelvis. Even if they aren't OP or asysnclitic the head still needs to rotate and mold. If you have a tight fit or the baby is right on the verge of popping past that pelvic arch you can apply mild pressure to one side of the pelvis (kinda like a hip press with just a little more pressure). This is a midwife trick used in home birth and I have had it work very well in some cases. At the same time I would use it with caution because although I've never seen it happen you might get a babies head wedged in and have a heck of a time getting them out by C/S. Sideling also helps allot when a patient is getting tired, they can rest better between contx. After pushing on both sides I turn them back to lithotomy and often the first push on their back brings the baby way down.

I try to keep my fingers out as much as possible because they can cause swelling. Keeping your fingers out also helps the patient feel more in control, less reliant on you and no matter how open your patient is, it's just weird to have someone's fingers in there. So once they can feel their babies head moving with pushes I only check here and there to make sure its coming down and to assess the angle.

I don't yell or raise my voice. I know that allot of people vigorously cheer their patient's but I don't like that. If I were the patient I would feel like I was being yelled at. I have from time to time used vigorous cheering on patient's that seemed to respond well to it or if I've tried everything else and the patient is getting tired.

Once the head is low enough I ask the patient if it's Okay for the Dad or partner to look at the head. Dads get really excited and this really motivates the patient and makes them happy.

Patients can have allot of anxiety about pushing so I keep things as mellow as possible. More often then not I keep the room dim with some upbeat but quite music (if they brought it). Often with teen parents or patients who are really scared about pushing I have a little pep talk that works well. It's one of the many talks I give so often it rolls off my tongue without thinking. I tell them that they can do this because this is one of the things their body was made for and even though they are scared and they don't feel that they can do this they will be fine. "You have strength deep down inside that you have never used. I can see the point where patients find that strength and you will find it too. Do you know how your mom always has the answers and how she always knew what to tell you to make things better? That's where that comes from. You will find it in pushing and it will help you to be a parent. You are stronger then you know." I've never had a C/S with someone I've given that talk too but then again I don't give it to the ones that I think are going to have a C/S because I don't want to be dishonest.

I only give as much instruction as is nessasary. Once the patient is doing it well I just praise her and do things to make her comfortable. As with most things I think it's important to tailor your care to the patient. I make sure not to do things only one way. If a patient does something weird but it works and is safe I'll throw my nursing handbook out the window and let them go with it. I think it's easy for us to fall into a routine and base care on what "we do" rather then what the patient needs so I'm careful of this.

I could talk about this forever (I've already come close lol) but it's time for me to go to bed so I'll stop here.

SmilingBluEyes · Jun 5, 2005

A great labor nurse/doula's resource:

The Labor Progress Handbook by Penny Simkin

this discusses in more depth the things Dayray and I discuss here. Hope this helps.

SmilingBluEyes · Jun 5, 2005

http://search.barnesandnoble.com/booksearch/isbnInquiry.asp?userid=In0Ri5JAu6&isbn=0632052813&TXT=Y&itm=1

see the above for more info on this very handy book.

asher315 · Jun 5, 2005

Thank you all for your replies, they were great! They helped answer alot of questions. I haven't seen any doulas around here and I wish we had them. Our c/s rate is waaaay high. Partly because most of our pts are scheduled inductions (mostly elective!) with questionable readiness (ft, thick, high and

38 wks). Partly because some of the nurses (all of them good) rarely have seen a natural labor process (one without starting with pit and AROM). I'm really a baby nurse but I have to attend too many c/s for failed inductions, failure to progress, etc. Just venting, I had a rough night at work with a PIA OB. :angryfire

Again, thanks for your input.

Sherry T :)

Kaseyrn2b · Jun 9, 2005

Here's my q...do you think some women are just physically for whatever reason, better at pushing? After working OB for awhile do you have a sense of what pts will have easier labors? And finally for those of you out there who were Moms before nurses, did your ideas about L&D change significantly?

Just curious, I had 2 pretty good labors & deliveries w/ my munchkins. My first was induced, DD was 2 weeks late(she still moves at her own speed, thankyouverymuch :) I had a midwife. I was young (23) and thought I'd go ALL natural. I thought I'd just squat in the corner, and that would be it. I could never get in synch, or on top of, so to speak, the pit. induced contrax. So, epi at 5 cm. My midwife was very cool, she never made me feel bad about it, she was like, whatever you want, no worries. My DD was born 1 1/2 hrs later, 10 mins of pushing, which I guess is pretty fast for a first time mom. Enter DS, baby #2. I truly wasn't sure I felt contrax, they were so different from w/ #1. I went for a labor check, ooops, 7 cm off to the hospital..DS was born 3 hrs later, again 10 mins of pushing. I had an epi right near the end, but very low. I felt a lot of pressure...I was glad in the end, he was 9 lbs! Anyway, that's my story. I'm starting clinicals next fall...I'm sure I'll be shocked when I get to my mat. clinicals, right?

Thanks for your time :)

FrumDoula · Jun 10, 2005

Here's my q...do you think some women are just physically for whatever reason, better at pushing? After working OB for awhile do you have a sense of what pts will have easier labors? And finally for those of you out there who were Moms before nurses, did your ideas about L&D change significantly?
Thanks for your time :)

While I certainly think some women's bodies experience pain differently, I also think pushing is a bit of a learned activity, particularly with an epidural. If a patient has cut off a lot of the feedback mechanism between her body and her brain due to the meds, then it's more diffiult to follow her instincts. And epidurals can sometimes cause malpositions, which make for difficult pushing stages.

Also, the position she pushes in can make all the difference. Lithotomy is almost always useless, and yet I still see it used fairly often on L&D decks. So that can extend pushing times, and make what would have been a normal pushing stage much more troublesome for the woman. So although it looks like her body is going slow, it may be the result of external forces.

Women with lots of psychological baggage will sometimes have longer pushing stages. (Sexual abuse comes to mind, or questions about the paternity.) Some women are so scared of tearing or so generally resistant to lady partsl birth that they'll push very ineffectively. I'm sure a lot of the nurses here can attest to that. So you either have to take charge and get a little bossy with your instruction, or you can work out the issues between contractions. Or you can watch as she gets the c-section she might have desired all along. Lots of different scenarios.

Of course, some women are simply destined to push for longer, given their physiologies, and some women simply have to sneeze. :) I pushed for 4.5 hours last time with a malpositioned baby. Let's hope it's shorter this coming time! :)

Alison