Archive for the ‘Hospital Birth’ Category

The Professional Doula: Maintain Your Role!

Calling all doulas- aspiring and experienced alike! Welcome to Part 3 of a short series on developing professionally as a birth doula. The goal of this series is to help you learn how to better serve the mother, work with care providers, and develop a good rapport while you’re at it. Be sure to visit the other parts of the series:

Part 1: Dress the Part

Part 2: L & D Ettiquette

The last installment of my short series is going to be brief and to the point. (Sorry it took me so long to write it!)

Doulas, what is your role? We’ve all heard many versions of the answer to the question “what is a doula?”, but generally they are all pretty similar. Here’s my own definition:

A doula is a non-medical, trained labor assistant who provides physical, emotional, and informational support to families before, during and after childbirth.

You may have your own variant on this definition, but one thing that almost everyone unanimously agrees on is that a doula is not a medical caregiver (unless she is a medical caregiver already who is simply acting as a doula at the time).

And yet, it seems that far too many doulas have a very difficult time restraining themselves when it comes to giving medical opinions, “cheating” at births by sneaking in food, etc., and other “infringements” on the non-medical restriction on our job. So how do you avoid the temptation and stay within your realm?

1) Give women information- not advice. If we really do believe that we stand behind evidence based care, then wouldn’t it make sense to let that evidence speak for itself? Give women resources and information to inspire them to do their own research. Always encourage them to come to an informed decision together with their caregivers.

2) Don’t argue with a doctor during a birth. Ask questions instead. As I said in Part 2 of this series, you need to keep your cool during a birth, even if you are in direct disagreement with a doctor. Phrase your disagreement as a question.

For example, instead of: “This mother doesn’t need pitocin! Her water has only been broken for an hour,” try something like, “How long after the waters are broken does the risk of infection increase dramatically?” Even if you already know the answer, starting with a question opens the doors to suggesting that the parents and doctor (not you!) can perhaps come to a decision on how long they feel comfortable waiting before beginning pitocin. 

3) Learn  policies & ask questions about them beforehand. Don’t be the one to break them. Your job during a birth is to provide informational, physical, and emotional support to the mother. It is not to disregard the hospital policies that the birthing family has already agreed to by choosing to birth there. Of course, you can encourage the families to ask for exceptions to the rules, but don’t blow them off. You don’t have the training, the authority, or in most cases, the financial resources to take on this sort of liability during a birth.

Remember, I am all for helping to change the face of birth in America. However, this should be done outside of your role as a doula through various methods of advocacy. When you are a doula, stick to the support you should be giving the family to ensure a job well done from all perspectives.

How do you maintain your role during a birth? What suggestions would you add to this list? How do you walk the fine line of doula and birth advocate?

Advertisements

The Professional Doula: L & D Etiquette

hands labor

Calling all doulas- aspiring and experienced alike! Welcome to Part 2 of a short series on developing professionally as a birth doula. The goal of this series is to help you learn how to better serve the mother, work with care providers, and develop a good rapport while you’re at it. Be sure to visit the other parts of the series:

Part 1: Dress the Part

Far too often I have overheard hospital staff talking about “the nerve” of other doulas, or listened to doctors talking about doulas getting in the way. Don’t be that doula! It’s still possible to serve the mother well while also cooperating with the staff. Here are some quick tips to having good etiquette in L& D.

1) Introduce Yourself. You are aiming to form pleasant relationships with the staff for the duration of the mother’s labor. Be friendly. Act professionally. Don’t be a standoff.

2) Ask questions. Show genuine interest in the staff & their activities. Make conversation as appropriate- obviously remembering that the mother is your first priority. Ask them how long they’ve been at this hospital. Ask if they have children. Ask if the day was busy for them. You’d be surprised how earnest and pleasant small talk can soften staff members that have a poor preconception of doulas.

3) Ask permission. Yes, ultimately, the mother should be able to get what she needs to labor comfortably. But the best way to do this is not by recklessly raiding the cupboards. The supplies are still the hospital’s, not yours. Just pop your head out to the nurses’ station and say, “Hey, do you mind if I grab a washcloth out of the cabinet?” or, “I know you’re busy right now, but when you get a chance could you point me in the direction of the extra blankets?”

Better yet, ask the nurses when you first arrive if they mind if you grab what you need as you need itDoing so ensures that you won’t be stuck in a hard place when the mother is in transition and needs you there almost constantly.

4) Think ahead. For that matter, try to ask a little bit ahead of time about as much as possible. It helps keep stress levels down and leaves everyone feeling prepared. For example, try to gently remind the staff about the couple’s desire for delayed cord clamping in between pushes, rather than right as the baby is being born.

5) Keep your cool. If you are faced with opposition, be polite. Don’t be mean-spirited in your replies. I understand that many of us are very passionate about birth issues. However, starting a fight in the labor room doesn’t help the mother or yourself. If there is disagreement over a procedure or policy, you need to stand behind the couple’s desires while still upholding respect for the staff. I would suggest the following format for your conversations with staff when a conflict arises:

  • I understand there is a disagreement over [such and such a procedure].
  • When the couple and I spoke prenatally, I know they were hoping for [such and such an alternative].
  • Would you be willing to present your concerns with the couple and discuss possible options with them? (Provided this is not an emergency, of course.) Perhaps a compromise can be reached.
  • Thank you for your understanding. I know this may not be your standard protocol, but as long as mom and baby are both healthy, I know they would really appreciate your flexibility in this matter.

Maintaining your professionalism will help your client’s case, not hurt it. And it will help you to develop rapport at the hospital while you’re at it.

6) Let the staff do their job. There are certain times in which you need to allow the hospital staff to take center stage. You should not have a problem allowing them to do what they need to do in these situations. Here are three examples:

  • They won’t want you near the doctor’s instrument table during pushing. Make sure you are not in the way.
  • If the baby needs resuscitation, you will not be allowed to hover over the baby until he or she is stable. Respect this.
  • If there is a true emergency, staff may need to move quickly. Step back and allow them to do so.

7) Say thank you. The hospital staff works very hard for a lot of women. They are usually on 12 hour shifts, on their feet for much of it, and are often being snapped at by stressed families. Many times they are left un-thanked for their work. Even if you weren’t particularly fond of a particular nurse or doctor, make sure you tell them thank you for their hard work! They deserve it!

Okay, experienced doulas… what have you learned over your time working in hospitals? Share your wisdom in the comments section!

Photo Credit

//

The Best of Both Worlds

One of the most common questions I’ve heard posed by those who oppose home birth is this:

“Which is more important to you- the birth experience? Or the baby?”

It implies that mothers who choose home birth are irresponsible. That they care more for low lighting, eating and drinking, and romantic photographs of labor than having the possibility and convenience of immediate medical care. That they are making the choice to birth at home as a trade-off- “Well, I understand my baby might die, but I really like my house better than that cold, sterile room.”

Of course those women who chose home birth cringe at the accusation. We love our babies just as much as those who chose the hospital. And home birth moms cry out that it’s not just the experience that draws them to home birth-it’s also the medical advantages that home birth offers.  It’s the lowered risk of hospital-based infections, the probability of faster, easier labor, the less likelihood of unnecessary interventions that can cause even more problems. They challenge the idea that the hospital is the safer place to be for low-risk mothers.

And both sides pull out studies. Both sides pull out horror stories or anecdotal evidence to support their own position. It seems that either you risk a life or you compromise your healthy, calm labor experience.

But I challenge you all.

My question is, why can’t you have both a beautiful and safe birth experience in either setting?

Why can’t home birth midwifery be legalized in all 50 states so that it wouldn’t fly under the radar, creating unqualified providers and dangerous birth settings?

Why can’t there be standardized training for those legal home birth midwives so that all mothers can get the safest care available?

Why couldn’t there be traveling OR units for cesareans at home in a true emergency, as one birth blogger suggested?

Why not require OB’s to have more training and experience with completely natural births? How about having to witness some home births before beginning practice?

Why not allow a mother to have a “home birth in the hospital?” All it would require is to allow a mother to labor freely under midwifery care, just as she would at home- only just down the hall from OB’s & the OR as needed.

Why can’t OBs provide the quality and continuity of care that mothers love when hiring a midwife- longer appointments, a holistic view of woman’s health, having the same doctor from prenatals to birth to postpartum care?

Why do money and legalities rule our health care decisions?

Why doesn’t the minority have the same opportunity to birth naturally and safely, just as women have the opportunity to birth with pain medication and/or in a more medicalized environment?

And why can’t these things change?

I know many of my hopes are only far off dreams… things that seem impossible now. But in reality, why not?  Why can’t we live in a world where we can have the option of more natural and peaceful hospital births, or the opportunity for a qualified home birth care provider for every woman who wants one?

Most of these ideas aren’t even on the horizon yet. But hey, a girl can dream, can’t she?

Photo Credit

You, The Consumer.

You are a mother. You are also a patient, or a client, depending on your care provider’s terminology. But, primarily, you are a consumer.

Photo Credit

Most of us don’t think of maternity care in this way- deciding to pay a specific birthplace and provider, rather than just going to the place that’s cheapest or where your friends went. But primarily, you are purchasing a service, not merely sitting under nonnegotiable care.

I am not writing this to undermine trust in your provider, or to encourage being a “bad” patient who is never satisfied. However, I think that there is enough variance in opinions, management styles, and routines among qualified providers to say that it’s fair to search for one who jives the most with your ideals. Let’s look at some examples.

Hospitals & Birthing Centers- First, look at the time limitations of  your hospital or birthing center. For example, our local hospital is the only one in about a 30-45 minute radius that provides maternity care, and only has 16 OB/GYNS who practice there, delivering around 3000 babies a year (at a 36.9% c-section rate). This means that this place is, in the words of several women I know who have birthed there, “a baby factory.” There is nothing wrong with choosing to have a baby there, but the implications of doing so must be considered. When there are literally not enough beds in the mother/baby unit and new moms are being made to share rooms with elderly men in the general sick patient area, you know that the hospital might be too busy. You know you won’t be receiving care from newborn nurses. You know there’s a possibility of  exposing your newborn to strange germs. You know you will lack privacy. You know you will lack sufficient one-on-one care. Yes, this hospital has a good NICU, round-the-clock anesthesiologist and cesarean availability, and a history of generally good outcomes (by American hospital standards), but does the high number of healthy babies at the end justify the means of care in helping them arrive?

Let it be known that not all hospitals are like this. I attended one about 2 hours from me that was much less busy, had only a 21.6% c-section rate, was quiet and calm, and had enough staff that the nurses could pop in whenever mom wanted them. Which of these two hospitals would I rather pay for their services? Certainly the latter.

One must also consider monetary influences on practices. (Before I write this, you must know that I don’t think all doctors/hospitals only want more money! I really do believe that they DO care about their patient’s well being!) It is worth noting that c-section rates are notably higher at for-profit hospitals than at non-profit institutions. Check out this news story for one example of this disturbing trend.

Home Birth Midwives

Time and money are also considerations for your midwife, though not as frequently as a big organization. How much does she charge? Does this correspond to her training and experience? How many clients does she take on a month? What is her back-up plan if she has two women in labor at once? You must know the answers to these questions before you hire her for your birth.

When hiring a home birth midwife, I think the most important consideration is finding out if you are paying for a qualified provider. As much as I support home birth midwifery,you  must remember that there are different breeds of midwife (CNM, CPM, and DEM), and there is currently no standard of certification for direct entry midwives. I’m not saying you shouldn’t hire one (my own midwife was direct entry), but you should make darn well sure that she is qualified to attend your birth before doing so. Find out her training and experience. Where and with whom did she complete her apprenticeship? Does she have references? Does she have a back-up doc?What is her hospital transfer rate, and what percentage is emergencies? What is her relationship to local hospitals? What are her maternal/infant/perinatal mortality rates, and for what reasons? How would she handle a hemorrhage? What equipment does she bring to a birth? Does she practice with legal integrity? I am not trying to scare anyone out of a home birth, but the safety of a home birth has been shown to depend upon the presence of a qualified attendant. Make sure that yours is.

Birth Philosophies– Remember, you are consuming services. Would you pay for a protestant pastoral education at a local college where the professors are Buddhist? Would you go to McDonald’s to purchase an organic beef hamburger? Would you go to the chiropractor’s office for heavy painkillers? No! Of course these are silly propositions.

Yet we do this over and over again when purchasing birth services. You might want a VBAC, but your provider’s successful VBAC rate is only 15%. “Too bad,” you say. “This is where our insurance takes us. I guess we’ll just work with it.” You have to think through how important your birth preferences are to you, and then choose (and sometimes actually pay for) a provider with a similar birth philosophy as you. You, the consumer, are responsible for picking a provider and birth place that support your desires. If you do not, then it shouldn’t be a surprise when things go differently than you’d hoped. Of course there are always aspects beyond your control, but you can make every effort within your power to ensure that you have purchased like-minded maternity care.

It has been said before that most people put more research into choosing a car or a stereo system than they do in choosing a care provider or birth place. Don’t let this statement be true of you. Make every effort to be an informed consumer.

I recently heard one of these statements myself: “If I were at home, my baby wouldn’t have made it.” While tragic outcomes can happen in any location, it is important to remember that one cannot extrapolate hospital events to home birth situations, nor home to hospital. The environments and practices of caregivers are far too different to make a judgement call as to whether or not you and your baby would have survived elsewhere.
I find that one of the most difficult challenges as a doula is knowing when to dispel the myriad of birth myths floating around, and when to quietly listen to a mother’s story without speaking up. There is a time and place for everything, and I am working on knowing the right times for each role. Any suggestions, anyone? Please read the whole post over at erinmidwife.com

erin midwife

A midwife in North Carolina was recently charged with practicing midwifery without a license because her state does not offer licensure for  Certified Professional Midwives (CPMs) and other direct entry midwives.  There was some local news coverage of the arrest and the ongoing efforts of North Carolina families to legalize CPMs.  One of the local news stories included a mother’s birth story from the “If I were at home, I would have died” perspective.

When I hear statements like this I cringe on the inside.  Being a midwife, I hear it a lot.  Women love to talk about their birth stories, as they should; Storytelling is a natural and beautiful part of our collective journey as women and mothers. In the park, at mom’s groups, among new friends, anywhere women gather there are stories of births and babies being told.  When I hear a story being told from the “I…

View original post 858 more words

What Makes a Hospital a Happy Place

I just attended a great hospital birth, and I wanted to share a list of things that they did that made mom and baby very happy.

  • They read mom’s birth plan.
  • They followed mom’s birth plan.
  • When they needed to suggest a change to mom’s birth plan for medical reasons, they discussed pros and cons, showed her great respect, and came to a compromise with her that satisfied both medical needs and her hopes for the birth as much as possible.
  • They followed evidence based practices.
  • They did not imprison her just because her water broke at first, but rather let her go home to keep checking her temperature and try to labor on her own.
  • They did not rush Pitocin. They gave mom lots of time.
  • When they needed to use Pitocin, they started it low, increased it slowly, and took her off of it once a regular contraction pattern was established.
  • They were willing to keep patiently adjusting my client’s monitors as she moved through many positions.
  • Once she no longer needed the monitors (because she was off Pitocin), they monitored her periodically by Doppler.
  • They encouraged movement and offered physiologic suggestions for promoting progress and moving the baby.
  • They did not even think of cutting an episiotomy.
  • They did not even think of cutting the cord early routinely.
  • Baby went straight to mom’s chest.
  • Baby had a chance to nurse immediately.
  • All checks were performed in mom’s arms, and the things that couldn’t be performed (weight, length, etc.) were delayed until mom was ready.
  • The hospital staff welcomed mom’s family and myself as part of a birthing team, not as extraneous people who didn’t know what they were doing.
  • They respected mom’s wishes and spoke to her kindly throughout the experience.

I really liked this hospital handled things (too bad it was 2 hours away from where I lived!).  They were very mother/baby friendly, natural birth friendly, and breastfeeding friendly. But, they never pushed anyone to do anything, and the only time they offered a change to mom’s plans were when it was for medical reasons. I felt the respect and support they offered created a warm atmosphere that made this labor and birth a more pleasant and healthy experience. I wish more hospitals were like this one! This was a beautiful birth that I was privileged to witness.

 

Homebirth: Preventative Medicine

When I would tell people that I was planning a homebirth, the same question would inevitably come up: what if something happens? You better get yourself to the hospital!

What if, what if, what if… The fact of the matter is that all those “what if’s” are a lot less likely to happen in a low-risk, unmedicated, physiologic, well-supported, calm birth. I would like to argue that, in many cases, having a homebirth with qualified midwives and the proper precautions (or a hospital birth where they treat you pretty much like a homebirth midwife would) is good preventative medicine against all of those “what if’s.”

(Disclaimer: I am well aware that not all hospitals are pushy, and there are many that are making huge improvements in providing evidence-based care. However, there are far too many out there that are still sorely lacking. It is these hospitals against which I hold complaint, not every single one. Also, I am quite aware that there are sometimes medical reasons for some of the interventions I list below. I am not against them as a whole. I only protest those which are done routinely or for unacceptable reasons. If the mother or baby need them for a medically indicated reason, by all means, they should be used.) That being said…

What if your labor stalls? Labor is much less likely to stall if the mom is comfortable in her environment and has freedom of movement to keep her baby coming down.

Having no epidural also keeps labor moving (epidurals often slow labor down) and sudden drops in blood pressure are much less likely. Mom will also probably feel much better after the birth since she won’t have any residual side effects from the drugs.

No narcotics for pain? Well, I suppose that means the baby will have less of a chance of abnormal heart rates and will be more alert to nurse after the birth.

No Pitocin to speed labor up? Baby will be less likely to suffer fetal distress since he won’t be subjected to the long, hard contractions caused by Pit.

What if you need a cesarean? Without all of these interventions causing complications, your chance of needing a c-section are greatly lowered.

What if the baby goes into distress? A watchful midwife at home will most likely catch problems in the early stages since she is only focusing on one patient-probably earlier than one nurse monitoring several patients in the hospital.

The list goes on and on…

Am I off my rocker? Please let me know if I am. It’s just that I’ve heard so many people who are concerned about the possible complications at a homebirth, but they don’t realize that those complications are FAR less likely if you are having an umedicated, physiologic, and carefully watched birth.

I obviously know that there CAN still be complications in any birth setting, some of them quite serious. For me the determining questions were:

1) In which birth setting would this complicatication be more likely to occur in the first place?

2) Where would the complication be caught faster?

3) Could they do anything in the hospital to change this that they couldn’t at home?

I think the answers to these three questions will be different depending on your individual care provider and birth setting. There is only one hospital to birth at in my area, and after much research I determined that home was the safest place for me to have my baby. I will let my readers decide for themselves, however, which location is safer based on their individual maternity care options. Please share your experiences- I would love to hear them.