Doulas?

onehusbandsevenkids · Jun 12, 2005

I generally start out in lithotomy position with the patient pulling back on her knees and tucking her chin. .

Hi there,

I am a mama to 7, a doula (on hold for now), studying direct entry midwifery (very slowly..lol) and a nursing student.

I'd like to say that I appreciate you taking the time to type out all of your replies in this thread. They were very interesting and informative.

I just am wondering why you usually use the lithotomy position?

You sound like an excellent L&D nurse, and I'm just curious as to why you have found that you use this position?

Thanks!

Dayray, RN · Jun 13, 2005

Hi there,
I am a mama to 7, a doula (on hold for now), studying direct entry midwifery (very slowly..lol) and a nursing student.
I'd like to say that I appreciate you taking the time to type out all of your replies in this thread. They were very interesting and informative.
I just am wondering why you usually use the lithotomy position?
You sound like an excellent L&D nurse, and I'm just curious as to why you have found that you use this position?
Thanks!

Hi there, I can understand why you ask this.

Without an epidural lithotomy is awful. The body was made to take advantage of gravity and the shape of the pelvis by squatting.

Epidurals differ from hospital to hospital. Where I work patients don't have the leg strength to squat. I will at times prop them up over the top of the bed but I don't pull out that trick unless I've tried my usual stuff and it isn't working. Even if you can get them up on their legs/knees they feel unstable so it's hard for them to push.

For my patients with epidural lithotomy works because they can focus on pushing rather then spending the energy to hold them selves up on week legs. It also allows me to help them know where to push. I've tried to get them more uprights but with an epidural it's really hard for them.

As for why I start there instead of side to side, Lithotomy is the easiset to assess fetal decent. As for why that is important.... I have to call the doctor to get them there on time. I don't want them there too soon becuse they get impatient or too late becuse patients want a doctor to catch their baby.

RNKitty · Jun 13, 2005

I do weary of the attitude some people have that I, as a labor nurse, am here to ruin their birth plan. Oh yes, I went through school and trained specially in this field so I can sadistically do things to you that you do not want done. In fact, I have spent 9 years here, so much do I love the power trip (and the liability, stress, paperwork, etc). Sometimes, people with a little bit of knowledge are dangerous. While I love working with a good doula, I will run from a bad doula who creates an atmosphere of conflict with the staff and confuses the patient.

onehusbandsevenkids · Jun 13, 2005

Hi there, I can understand why you ask this.
Without an epidural lithotomy is awful. The body was made to take advantage of gravity and the shape of the pelvis by squatting.
Epidurals differ from hospital to hospital. Where I work patients don't have the leg strength to squat. I will at times prop them up over the top of the bed but I don't pull out that trick unless I've tried my usual stuff and it isn't working. Even if you can get them up on their legs/knees they feel unstable so it's hard for them to push.
For my patients with epidural lithotomy works because they can focus on pushing rather then spending the energy to hold them selves up on week legs. It also allows me to help them know where to push. I've tried to get them more uprights but with an epidural it's really hard for them.
As for why I start there instead of side to side, Lithotomy is the easiset to assess fetal decent. As for why that is important.... I have to call the doctor to get them there on time. I don't want them there too soon becuse they get impatient or too late becuse patients want a doctor to catch their baby.

Hi again,

Thanks for taking the time to explain! Have a great day.

onehusbandsevenkids · Jun 13, 2005

I do weary of the attitude some people have that I, as a labor nurse, am here to ruin their birth plan. Oh yes, I went through school and trained specially in this field so I can sadistically do things to you that you do not want done. In fact, I have spent 9 years here, so much do I love the power trip (and the liability, stress, paperwork, etc). Sometimes, people with a little bit of knowledge are dangerous. While I love working with a good doula, I will run from a bad doula who creates an atmosphere of conflict with the staff and confuses the patient.

Well, I think in a lot of areas especially those with more "birth educated" parents, there is a general feeling that the hospital policies, control freak docs (especially those who have zero trust in the birth process and need to actively manage every step of the way), and the whole insurance liability issue can really interfere with normal birth and I think you'd have to admit that a percentage of the time policy/proceedure doesn't agree with what is ultimately best for mother and baby. Alot of what is done ultimately is what's best for hospital, doc and insurance co. Bottom line. I mean how many OB nurses are there that are working and quietly trying to change "the system"

each day on their own shifts? There ARE problems and I think the public has become much more aware of them in recent years.

So, I think people are just defensive going in. I think some upfront, very friendly supportive communication goes a long way in easing parents minds when they come in.

I am a doula, and my very best friend is a L&D nurse, we have both seen many, many examples of these situations. In several different facilities in two different states. There are so many "horror stories" and I know there are just as many "great stories" too but the horror stories will always get more attention, ya know?

I think the nurse bears the brunt of this fear/anxiety due to simply being the one who is there caring for the patient the most.

I don't really agree with you that knowlege is dangerous, quite the opposite, (one of the major duties of a doula is to make sure the parents are educated and are aware of ALL of the options so that THEY can have an educated and truly informed consent) but there will always be those who are extremists and very distrustful. JMHO.

RNKitty · Jun 13, 2005

I don't really agree with you that knowlege is dangerous, quite the opposite, (one of the major duties of a doula is to make sure the parents are educated and are aware of ALL of the options so that THEY can have an educated and truly informed consent) but there will always be those who are extremists and very distrustful. JMHO.

I didn't say knowledge is dangerous. I said a LITTLE knowledge is dangerous. Big difference. You have to figure that an MD that has been through 8 years of school and 4 years of residency, and a nurse with a MSN in Perinatal nursing might possibly have access to more information than a doula with 2-6 weeks of training who is "interpreting" medical advice for a patient.

Dayray, RN · Jun 13, 2005

I didn't say knowledge is dangerous. I said a LITTLE knowledge is dangerous. Big difference. You have to figure that an MD that has been through 8 years of school and 4 years of residency, and a nurse with a MSN in Perinatal nursing might possibly have access to more information than a doula with 2-6 weeks of training who is "interpreting" medical advice for a patient.

I have to agree with this. Doula's are great as support for the patient, which is just as important as the other things nurses do. However, I find that many times the information they provide to patients is very biased. Also too little information can be a dangerous thing.

There really are things that doctors and nurses learn in school/practice that cant be found in natural labor books or in attentding 2-6 births. For this reason I feel strongly that child birth education should be left to people with more training then doula's/ child birth educators.

Doula's do have a very valuable place but I find the requirments for their certifacation too loose for them to be giving medical advise. I have worked with some awesome doula's. I would trust these people to teach classes becuse They know more then what they learned in their doula certifactaion.

Too many times I have seen confused and scared patients becuse their doula said..... or patients that are taught that the nurse is going to steal their birth experance.

BabyRN2Be · Jun 13, 2005

I've been a doula for 8 years and I've had the privilege of attending more than 150+ births. I also plan on attending nursing school in two years. Currently I work in a hospital that has a volunteer doula program. If pts. meet the criteria for needing a doula (The triage goes something like this: No. 1 - primip, no support, No. 2 - primip, some support 3. multip - no support 4. mutip - with support), they can have one. I have learned so much from this program and I truly understand the nurses roles and why they do what they do. The nurses aren't here to "ruin" birth plans with power trips. What does bother me is a doula who shames her client out of medication and the client goes through a 48 hour birth full of terror (is the pain ever going to end?!?!) Good grief, we are here to support joy in birth and creating positive birth memories. What's the positive aspect in going 48 hours in trauma and terror?

I want my private client to look back on their births and see positive memories. If I believe that a client would benefit from an epidural, I'll quietly say, after all has been exhausted (and before the mom is, too), "Hey, Shelly. I know that we've been working together for a long time on this. You are doing an awesome, wonderful job, but it won't be a bad thing if you get an epidural right now. It will let you rest before the pushing phase, and sometimes if you get the epidural, you can relax and that will allow the head to descend." (I'll usually say this to a client who has been at 5cm for 7 hours and who I know will not come back at me later saying "WHY DID YOU TALK ME INTO AN EPIDURAL???"). Depending on the pt, I might say, "You've been working awfully hard for the past 10 hours and things are going great. However, I know that you might be concerned about things and I know that you're having a tough time getting on top of ctx. It wouldn't be bad if you considered a bit of Stadol just for this time." (Only if she is within the window for Stadol).

I know that there are A LOT of doulas out there giving those of us who entered the profession gently a bad name. By "entering gently" I mean, by listening more than speaking during a birth, getting to know my limitations, and really reading the fine print on the DONA Scope of Practice which says that it's out of our scope to give information on how pit works, and NEVER go about adjusting a pit IV. I couldn't believe it when I read that... I'll only touch on button on that IV pump and it's only after asking the nurse, "Do you mind if I silence the IV?"

Why did I enter the profession slowly? I know that I didn't have enough information after attending a two day class to go about managing a woman's labor. That's why I read MANY books, other than DONA's list of reading. I read medical textbooks on labor (my mom's a nurse and she happened to still have her Maternal Child Health textbook, thanks, Mom! :)). I asked many question of the doulas who I knew were once nurses so that my knowledge was tempered and even. I know of the doulas that some of you hate, the ones who come into the room and place themselves between the pt and the nurse. The ones who only give the cons of an epidural instead of the good that can come from an epidural, especially to a mom who is having a tough labor.

I know of one doula who didn't let the patient speak and presumed to know more about birth than the mom and the nurse put together. She did know enough about medicine and, and I that this is going to sound unbelievable, had a pregnant friend fake an emergency to this pts same doctor so that he would be tied up when the pt was ready to deliver. This came about when the doc said something to the laboring mom that she (the doula) didn't like (it was in regard to walking with ruptured membranes) and the doula wanted the doc busy during the rest of this woman's labor.

Another doula is forbidden to attend births at a hospital in this city because her client had a premature urge to push and the nurse told her not to push yet. When the nurse left the room, the doula told her client to do whatever her body told her to do and to go ahead and push. She'd count. The nurse didn't design the client's body so she couldn't possibly know what she was talking about and to do whatever she felt like. End result? You guessed it. It went on for a while, her cervix swelled so badly she had to have a c-section.

I just shudder when I hear stories like these. There are many doulas out there who have their hearts in the right places and truly see the nurse on their team, altogether to help the pt have a safe and healthy birth.

The nurses seem to be split at our hospital. As Dayray suggested, some of them see us as wanting to be the nurse. Many of the others see us as someone who is there to help them. Especially if a pt is on the call light every two seconds or is screaming so loudly at 2cm that they can be heard at the nurse's station. We know our jobs, and what we should and should not do.

BTW, we have a statistician checking our facts and benefits to the hospital. In 2003, the volunteer doulas saved the hospital $40,000.

Hopefully one day I will be a nurse, and I will know what it is like to be a doula trying to help, and I hope that they see me as being on the same team, with the goal being a safe and healthy birth for both mom and baby.

SmilingBluEyes · Jun 14, 2005

I like one thing you said, BabyRN2be......we all should try it more:

"listen more than speak" in the birthing situation. Maybe we all could do that more often. I think in listening to our patients more....we may learn a lot. I also think we all stand to learn from one another. But most learning is done when our own mouths are not going 100 mph. Good point!

BabyRN2Be · Jun 14, 2005

Thanks Smilin.

I also wanted to say, if ANYONE ever encounters a doula who is going beyond her scope of practice (resetting IV's, giving medical advice over the phone, etc.), find out her name. Ask if she's certified (if she's not defensive). You can find out later on if she's certified, it'll be either through DONA, CAPPA, or ICEA (those are the big certifying organizations). I recommend that you report her to her certifying program because you can file a grievance against her, especially if she's doing something that doesn't even begin to fit in her scope of practice (like resetting IV's... UGH. I can't believe that happened).

Doulas can be a huge help to everyone, mom and nurse. If there's something that can be done to weed out the bad ones, progress will be made and doulas will be seen in a more positive light.

JoniL&DRN · Jun 16, 2005

Babyrn2B.. I love the idea of this volunteer program! I am going to begin my clincals in January and I'm going to pursue my doula certification this fall that so that I can hopefully have some experience with the less medical side of childbirth... I plan to go to midwifery school after all this is done!!

I think the volunteer idea is just great and I wonder what kind of patient confidentiality issues there are...We have a LOT of teenage moms in my area and I know they could use the emtional support for sure. I think they often delivery withour benefit of the father around. Could I maybe get something like this going in my area? We don't have anything like that in place now. You have inspired me!!!

BabyRN2Be · Jun 16, 2005

Babyrn2B.. I love the idea of this volunteer program! I am going to begin my clincals in January and I'm going to pursue my doula certification this fall that so that I can hopefully have some experience with the less medical side of childbirth... I plan to go to midwifery school after all this is done!!
I think the volunteer idea is just great and I wonder what kind of patient confidentiality issues there are...We have a LOT of teenage moms in my area and I know they could use the emtional support for sure. I think they often delivery withour benefit of the father around. Could I maybe get something like this going in my area? We don't have anything like that in place now. You have inspired me!!!

Joni,

That's a great idea! After you get your doula certification, approach the hospital about it. We have a great person who put the one at my hospital together, but I don't know how she went about doing it. I suppose you could start at the auxiliary office at your hospital and approach them about a volunteer doula program (I think that I mentioned in my post that we saved the hospital money... I'm sure that they would be all for that!).

I do enjoy attending births for moms who have no one else there with them or for them. They are truly grateful you are there. You may check in your community to see if you have a local doula group and see if there's a hospital that has a doula program already in place.

I do hope you can get a volunteer doula group in your area started! Good luck to you and I hope all goes well!