labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Tuesday, August 28, 2007

Doulas Are Awesome

You will often hear moans and groans from many L&D nurses from coast to coast when a woman shows up with a birth plan and/or a doula. Many nurses (and doctors, even midwives…or shall I say med-wives) believe that any woman who writes out specific plans as to how her labor shall occur are subconsciously asking for a c-section. They hate the thought of someone else trying to take control of the birth. The hospital is the doctors’ and nurses’ home turf and the best results occur when the away team (aka Mom and Dad) follow the rules. Birth plans challenge this, and are quite threatening to those who like full control on their own turf.

But actually, what I meant to get into was doulas. Doulas are trained in labor support. They provide support and assistance continuously while a woman is in labor, and some may also provide help after the baby is born. Many times doulas like to meet their future mothers during the pregnancy to get to know them, and make sure that there isn’t something that would inhibit the doulas work (like the mom and doula not liking each other). Just about anyone can call themselves a doula, but don’t be fooled. Doulas must be certified by either Doulas of North America (DONA) or Childbirth and Postpartum Professional Association (CAPPA).

I personally love doulas. Unfortunately, very few women have doulas where I work, and there have even been some women who were denied their doula. Apparently there aren't many doulas in my area and the one that most go to is “not allowed” in the labor rooms per the medical staff. She was accused of interfering. My feeling is that she probably is an outspoken advocate of her clients, and therefore challenged some of our old school thinking docs.

The reason I love doulas at work is because it frees me up. Isn’t that terrible? Traditionally labor and delivery nurses were meant to provide the continuous labor support to women. However, this has historically not been the case. When childbirth was moved to the “safety” of the hospital, nurses were to assist the obstetricians. I have a nursing textbook from 1922 that gives a litany of duties the nurse was to perform.

Many of the duties have changed, but 2007 is essentially no different for a labor and delivery nurse than for the 1922 labor and delivery nurse. The difference is in what we have to do. There are monitors to maintain. Paperwork and charting to kept on top of and meticulous in case we have get deposed. Interpretation of fetal heart tones and maternal vital signs. And many times one nurse is caring for 2 or 3 woman at once. I am totally simplifying what L&D nurses do as far as our “tasks”, but my point is that very little of our time is left over for actual contact with the woman. So as you can see, doulas do what I wish I could be doing. They do what the woman deserves during her childbirth experience.

Research also shows that women who have continuous labor support have shorter labors, fewer interventions, less pain medication, to name a few. Most importantly, most women will report a greater satisfaction with their experience, even if they ended up having a c-section or epidural. I’ve done a cursory review of the literature and have come up with some titles that might be helpful. I’d link directly to the articles, but I’m told this is illegal. Find Articles might be helpful, or just google it.

This is a meta-analysis demonstrating some of the positive effects that continuous labor support has:

Zhang, J., Bernasko, J. W., Leybovich, E., Fahs, M., & Hatch, M. C. (1996). Continuous labor support from labor attendant for primiparous women: A meta-analysis. Obstetrics and Gynecology, 88(4), 739-744.

This article is interesting for many reasons. It has a small section on continuous labor support but I think you will find other pieces of it interesting:

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). The nature and management of labor pain: part 1. Nonpharmacologic pain relief. American Family Physician, 68(6), 1109-1112.

I found this one interesting because they trained student nurses to provide doula care, and the researchers imply that institutional changes should occur to allow more nursing support of the laboring woman:

Van Zandt, S. E., Edwards, L., & Jordan, E. T. (2005). Lower epidural anesthesia use associated with labor support by student nurse doulas: Implications for intrapartal nursing practice. Complementary Therapies in Clinical Practice, 11(3), 153-160.

If you were going to read only one of these articles I list, then this is the one. It’s a case study that is discussed by several different professionals from different perspectives, while reviewing the benefits of doulas.

Stein, M. T., Kennell, J. H., & Fulcher, A. (2004). Benefits of a doula present at the birth of a child. Pediatrics supplement 3 of 3, 114, 1488-1491.

For those interested in having a doula but don’t know where to start I would suggest DONA’s website. They have a search feature to find doulas in your area. Meet with potential doulas to get a feel for her (or his) style. Also, talk with your doctor or midwife about doulas. You’ll learn a lot about his/her philosophy of birth by what they have to say about doulas.


Gail said...

Wow... I just went thru my first birth as a doula and appreciate your opinion of doulas.

Matt said...

Speaking as a doula, thank you for this post. :)

Redspiral said...

There is no legal or professional requirement for doulas to be certified, nor are DONA and CAPPA the only certifying bodies!

I have chosen not to certify as the standards aren't high enough for what the word 'certified' implies. If there were higher standards, I would absolutely do it.

It's unfortunate when doulas are removed from the labor room but if she is indeed inhibiting the relationship between her client and the client's provider, then I think it's a fair call to make. Doulas should not be mixing up their hats- doing vaginal exams, interpreting test results, making demands... this is not a doula's role but unfortunately because there is a distinct lack of standards in the doula profession, the doula herself is free to determine what her scope of practice is, unless she has certified. So yes, I can determine how I choose to practice with no consequences professionally. And ultimately, even if a doula was removed from her certifying organization, she would still be able to practice. There just aren't any standards in place, and so many hospitals are requiring their own standards be met. Some hospitals require doulas sign an agreement of what they will and won't do, and it can be quite limiting, or sometimes it's just a technicality. Some doulas or doctor's clinics BAN doulas all together!

A good doula (IMO) would never put herself between a client and provider. It's just not her job, and it causes more strife than it saves anyone from. I worry when I hear that doulas were banned from hospitals because it's rarely ever "all doulas" and it's usually one specific doula who was caught doing a vaginal exam or arguing with a doctor, or pushing her client around. It happens, unfortunately. Doulas who want to be midwives, want to be in charge...

Also, here are a few more links to add to your list! <-- birth doulas and childbirth educators <-- birth and postpartum doulas, and childbirth educators <-- childbirth educators and birth doulas


Redspiral said...

... and I forgot to say...

Labor nurses are awesome.


I've seen nurses make and break birth experiences, I've had nurses come in and in one movement say the exact thing I couldn't articulate to my client after many hours supporting her. I've been treated with respect and encouraged to participate, my ideas have been valued and even requested -- of course I've experienced the opposite but it's rare, in my experience. I am usually either tolerated or really welcomed, and most often, I'm very welcomed. The energy this brings to the room can not be duplicated and is invaluable. :)

Even if L&D nurses aren't giving everything they could be (due to patient loads and all that charting, holy mackeral!), I hope you never dismiss or minimize the incredible energy you bring into the room every time you walk in. It can't be replaced. :)

tofu lou said...

yay for doulas! i've doula'd at... 8 births. three hospital, five birth center. at the hospital births the nurses we great... it was the DOCTORS that wanted to know who i was, what i was doing there. ugh. i've had a few "run ins" with docs (less John) but all is well. like i always say, i'm there for mama, the doctor is there to deliver baby.

i once doula'd for a mom during her 8th (yes e-i-g-h-t-h) birth. i just did my thing and she was AMAZED at how smoothly her labor went and how much she learned about the whole process and about her baby. that was a good experience in reminding you that just because someone has birthed a buncha babies doesn't mean the always know what's going on.

Anonymous said...

You can link directly to the articles; it's not illegal. No one will get the full text for free unless their institution or organization has a subscription. You would only be violating copyright if you posted the PDF or HTML of the whole article yourself. Just linking to the citation is not the same thing.

Glad to have you back with a new blog. I was sad when you stopped publishing your old blog.

Labor Nurse said...

redspiral, I guess I thought doulas must be certified to officially market themselves as doulas. Like I said in the post, anyone can call themselves a doula. However, I think that someone who takes the time and effort to become certified shows that they are committed to what they do. Even if there are no standards (Nurse Practice Acts differ state to state, so there is technically no one official standard even for RNs!) that are consistent of high enough to be called standards, it at least shows the doula wants to portray her commitment and/or professional credits.

As far as the doula that is not allowed on my hospital's campus, I think it may be due to her being "too strong" of an advocate. My guess is that a doctor said they wanted to do something interventional on the woman, and perhaps the doula and woman previously discussed that she wanted to avoid this. The doula may have said so and said it quite forcefully. I have only met this doula once, very briefly, and my impression was that she was very mistrusting of the medical establishment.

kristina said...

I was just going to comment about many other certifying agencies out there but RedSpiral beat me to it. Each have their own Standards of Practice and Code of Ethics, and moms might benefit from reading them to fully understand how their doula is trained and where she draws the line on certain areas.

Also in my DONA training, we were taught that anyone can call themselves a doula - doulas can be certified, but there isn't an agency that licences (like RNs). I agree that doulas don't have to be certified to be great doulas as I'm sure Reddy is (just from reading her blog for forever tells me that) but there are some women who are just the mom's friend with no training and they step in and call themselves the 'doula' and I believe that lowers the profession when doing so.

WelcomingBirth said...

Hi Labor Nurse,

I beg to differ on the "someone who takes the time and effort to become certified shows that they are committed to what they do" comment :-)

I am NOT a doula (but a childbirth educator who knows many a doula). It might be true that someone who goes through the process of certification is commited, but I know many 'committed' doulas who are NOT certified. Most of the time they are choosing to not be certified for political/philosophical reasons (particularly when it comes to DONA it seems).

If I was looking for a doula, I might be interested in knowing if they are certified but I would be more interested in my 'connection' with them and their philosophy and style of practice.

Just my .02 cents!

Anonymous said...

I am 38 weeks pregnant with our 2nd child. Having a doula sounds great. I don't know if it's too late to arrange for one for this pregnancy. I was just wondering what the approximate cost/fee for a doula's services would be? I live in Texas if that makes a difference.