You Buy the Hospital Ticket...You go for the Hospital Ride
(I originally wrote this in mid-2006. It's just as relevant today.)
Once upon a time, doulas were in the birthing arena to help women achieve the births of their dreams. I distinctly recall telling women I would be a go-between for them between the medical staff and themselves, the laboring couples. At doula trainings and gatherings, I know I heard doulas teaching each other how to be manipulative with the staff, yet soft-spoken and seeming demure and obsequious.
Doulas had code words to use that meant "Time out! Ask the medical staff to leave so you can talk alone (and by alone, I meant with me, too!) before deciding yay or nay." Doulas right in front of my face (was that a mirror I saw?) - and the doctor's - said things like, "Remember when we talked about your birth plan last week and you said no matter what, you didn't want an epidural?" or "Do you want me to remind you of the risks of that position before they put your legs in the stirrups?" or "Doctor, doesn't pitocin rupture uteruses?"
It wasn't a decade before the role of the doula began shifting. Once DONA (Doulas of North America, now DONA International) jumped in and incorporated the concept of a doula into a profession, we'd already heard about "renegade" doulas that commandeered labor rooms and antagonized the staff so dramatically, doulas were threatened with expulsion from labor and delivery rooms around the country. Therefore, DONA grabbed the opportunity to squelch such power-tripping by insisting that doulas not speak on behalf of the client or her family.
Doulas were not permitted to do anything that smacked of medical or midwifery care - no fetal heart tones, vaginal exams or blood pressure checks (something many doulas had been doing for years). DONA snapped the profession's back into sharp attention, kept her hands stiff at her sides and instructed for her (the multitude of doulas) to keep her eyes straight ahead and not look around.
By doing this, DONA saved the role of a doula, if not the very word itself. Doulas began changing their spiels to encompass words such as "supportive," "reminder," and "belief in you" - removing forever, at last in any literature or in public venues, the implication of advocate or director. Accepting that the changes were the only ones that could be made, women were suddenly back in control of their own birthing destinies.
Or were they?
Back to the beginning once again, the issues that brought doula-dom into existence in the first place - archaic birthing practices, patriarchal attitudes towards laboring women and unsubstantiated reasons for a plethora of rules and regulations - remained. What's an enlightened woman to do?
Why, create a birth plan, of course.
Birth plans, in existence long before there were doulas (either in name or in idea), over time, have become more and more explicit and restrictive. I have easily read over 3000 birth plans and can tell you the grand majority of them are the same in 98% of their content.
• No episiotomy
• Allowed to move around in labor
• Allowed to eat and drink
• No formula or pacifiers
• Dad to stay with me the entire time
• No enema (yes, I still see this on birth plans)
• No shaving (unless you live in the backwoods of medical care, this is so absurd to put on a birth plan it is laughable - mostly laughable to those you are speaking to, the nurses in labor & delivery)
... and the litany goes on and on.
Interestingly, there are dozens of websites and hundreds of baby-oriented books that make a birth plan into a formula for folks to fill in the blanks. How creative of them! It is extremely frustrating getting a cookie-cutter birth plan - as mentioned above, so many are exactly alike, why does anyone write one at all? I'm all for using one of the pre-planning birth plans as a template so your own needs and desires can come out of hiding. Sure, if you don't know what your options are, how will you know what to choose? But, my point is, once you have chosen, dump the look-a-like and create your own plan... with your own words... your own personality.
And make the thing SHORT. I mean short short. A 3x5 card on one side. Double-spaced.
(I can hear the ruckus even now. "But, you're just saying you don't like them because it limits you!" or "You would say that, you medwife person. You don't want anything individual interfering with your care." Bull. I'm telling it like it is to save your butts in labor and delivery! I'm trying to help you understand how tired they are seeing birth plans, how they never read them [unless you get some alien nurse who happens to be in midwifery school] and how it is a waste of your energy to write the same same same same same same same same thing as every other person that comes onto their floor. Dispense with the extraneous and write what matters!)
• I will ask for pain medication. PLEASE DO NOT OFFER IT TO ME! (Make a pretty sign and tape it to the outside of the door. Make a couple in case it disappears.)
• Please, keep lights low unless it is crucial to my life or that of my child's. (Another great door sign.)
• Please KNOCK before entering (Door again.)
• Risks, benefits, consequences of refusal and alternatives are to be discussed before EVERY procedure on myself and my baby. (I learned that "informed consent" does not legally mean discussing risks and benefits. Watch that blanket form you sign upon check-in!!! It allows them to say they obtained informed consent.)
It’s important to remember you attract more flies with honey than with vinegar; be kind, but be direct.
So, looking at that list, doesn’t that set the stage for retaining autonomy and letting the providers know your wishes? It’s also important to be open to listening to what they have to say. They absolutely might have something valid to share. It's been known to happen. If the above points aren’t your hot button issues, make your own points - but make them succinctly.
I believe the main reason for a birth plan is to facilitate communication between the parents... allowing them to see how each other feels about such important things like pain medication, circumcision and even vaccinations. Birth plans are great for everyone talking to each other. If it worked with the doctors and nurses, all the better, but it usually makes for some pretty antagonistic and stiff discussions in a prenatal visit and a bunch of rolling eyes in labor.
Once again, if you buy the hospital ticket, you go for the hospital ride.
If you buy a house and stand inside your palatial mansion saying to the builder, “But, I wanted a log cabin!” - the builder might wonder what the heck you were thinking going to a master-palatial-home-builder instead of a log cabin specialist.
If you want soy milk, don't milk a cow.
Why... why oh why... if you want a "home-like birth inside the hospital" aren't you considering a home or birth center birth? If you want control, why go where egotistical birth is the norm? If you want autonomy, why go where lawsuits and defensive medicine are the rule?
Ohhhhhh, because it's safer? Is that what you think? Oh!! I see. Well, if you believe hospital birth is safer and that's why you want to be there, then BE THERE - with all it has to offer... in all its guises... in all its paranoid glory. Why would you try to manipulate a hospital's/doctor's/nurse's actions any more than you would try to manipulate the car mechanic's? If they aren't good enough for you, find another! (This is, of course, where choice is an option. I don't live in a dry well.) You're hiring someone to do the best they know how to do. LET THEM DO IT.
It is so funny hearing me say this. I really did used to be the doula who could get it all for her client - I am a great doula and monitrice - but it is more frustrating than words can say when a client says things like, "No drape between me and the incision during my cesarean because I want to watch." How the heck are you going to see your pubic area? You even can't see it when you are standing upright and leaning over! The curtain isn't just because you might not want to see the surgery (if you could remotely see down that far in the first place), but it is also in case you projectile vomit into your incision.
Note: Hospital rules are not in place to annoy you. Some are really important to the life and health of you and your child. Do people forget that? (Yes.)
I do understand that a number of women don't have a choice about where they deliver... there aren't midwives, the doctors are all the same, hospitals won't let them do VBACs... I do understand. However, in that case, I have found that going along for the ride makes for a much better experience instead of fighting the whole way. I don't want that to be a rape or abuse analogy at all, but one of "if that's what I have to have, then let me be gentle about it and see how good the experience can be."
I have seen women who go in without pre-conceived plans have far better birth experiences, with less tension and worry, than women with elaborate desires and wishes written down or vocalized. Women tend to be treated more kindly if they seem to be on the same page as the nurses' and doctors' agendas. This might be wrong or unfair to some, but is the truth.
So, how would I counsel someone who medically needed to be in the hospital? I would encourage remaining open to what the nurses and doctors had to offer. If they offer something the woman doesn't want, say, "No thank you." Simple. Concise.
I’ve been to births where my clients had no scripted birth plans and who had beautiful hospital births - ones where the nurses were respectful and we were left alone a great deal of the time to talk and laugh and spend time with each other.
My concern, and the reason for writing this piece, is in unrealistic expectations - across the board... with the client, her family, the doula, the childbirth educator... even midwives. Sure, docs and nurses also have unrealistic expectations, of another sort; many (most?) believe every woman has to have an epidural to have a happy birth experience, or that no one should have a VBAC. Those untruths are as incorrect as the ones that say if a woman has a birth plan she'll have a better birth.
I simply do not see that as realistic - or even close to happening in real life world. Far more often, I watch as hard worked-for plans fall away and women feel more and more guilty and sad for the draining away of their desires. What if we worked on changing the reality of those desires? What if doulas and birth assistants and childbirth educators bluntly laid things on the line and said, "Just because your doctor agreed in the office doesn't mean it's going to happen in real time. You might never see your doctor again. Your doctor, after listening to your birth plan in the office, might know he will have to convince you once you are in labor that his/her way is the way to go.” It is almost impossible to tell what someone will do (midwives included) until after the fact.
Doctors often say there is no such thing as normal birth except in retrospect. The same can be said for a provider doing what they say they will do.
Maybe if we (doulas, childbirth educators, midwives, nurses, doctors, etc.) all got real with women, they might make different choices altogether. Maybe they would get really cranky and start demanding more humane births instead of the lip service paid, touting million-dollar renovations in lieu of hiring more nurses with compassion and a gift for listening to women in labor... not just wanting to get them drugged and quiet.
I don't know what the absolute answer is, but I do know it can't keep going the way it is... everyone fake dancing that each side is listening. Really, knives are stabbing each other, scalpels cutting bellies, women medically paralyzed, drugs given to women begging for natural births - doctors and nurses working in a haze of "what will this look like in court?" and really, really believing they are doing the best thing for the health and safety of the mother and child.
Someone needs to just speak the truth. And it starts with me.