Friday, December 14, 2012

3 Years In: Reflections on Birth and Being a Doula

There are many instances in which a blogger says exactly what I've been feeling in a way so perfect that I could never have said it so well.

Recently, Gina (aka The Feminist Breeder) wrote a post reflecting on being a doula after 20 births. I'm almost to that number myself, but I haven't taken the time to actively reflect on how my outlook has changed. But reading her post, as well as Kristen's (Birthing Beautiful Ideas) recent post "I Don't Think You Should," makes me think of how being a doula has made me feel over the past 3 years.

http://www.gentlebirthchoices.com/what-is-a-doula/

Gina writes that she purposely doesn't mix her doula work with her blog. I feel the same way - I don't tell my clients that I have this blog and I don't use this blog to find clients. Some people have said I should - "but you have great information on there for your clients!" or "a blog helps people find you and want to hire you!" But I have always enjoyed having this as a place where I can say what I think and feel without worrying about past or potential clients wondering if it is about them, if my opinions might change what they think of me, or thinking that I'm going to bring all of my extreme activism into my relationship with them. As Gina puts it: "I do not bring my unfiltered self into the births; I bring only my experience, my knowledge, and a big heaping helping of empathy"

What a woman and her partner need during birth is freedom of choice and lack of judgement. The number one thing that a birth partner must learn (and perhaps say over and over to herself in her head) is "it is her birth, not mine."

A lot of my opinions about birth have changed over the few years that I have been attending births in hospitals, birth centers, and at home. In 2010 I wrote a post reflecting on how my mindset about epidurals had changed, based on a post written by Rebecca (Public Health Doula) on the Stages of Birth Thinking. Click over to read the entire post, but here it is in a shortened version:

There is Pre-contemplation:
This generally means that birth education comes from mass media portrayals of pregnancy and birth, as well as personal stories from friends and family that may vary greatly, but are usually filtered through the prism of our culture's main messages about birth: Painful and pathological; done in a hospital, with doctors. You might prefer a vaginal delivery or a c-section, but there's little you can do to control the outcome, and all hospitals/doctors practice more or less the same way,
then Initial learning and Revelation:
 "Wow! Nobody ever told me that birth could be amazing, not scary! These home births are beautiful. I didn't realize that my/my friend's/my aunt's c-section could have been prevented. I didn't know about all these harmful complications of interventions - I've only heard good things. And it's so clear how once you start one intervention, you get a cascade of them. Doctors don't have the best outcomes - midwives do! Breastfeeding has benefits I didn't know about, and they are so important."
then Validation (or not) through Experience:
A year of attending births nudged me yet farther away from my starry-eyed novice doula perspective. Not all c-sections can be avoided, even if you do everything "right". Sometimes epidurals are the best tool you have. Pitocin isn't fun, but it's not the end of the world. While it might be difficult to accomplish, you actually can have a great low-intervention birth in a hospital. This tempering is slow, and less personal - it's not happening to you, and it's happening over a multitude of experiences.
and finally Integration: 
You recognize that every situation is individual, even though there are patterns and large-scale effects that are likely, because you have a chance to see many [births].

I think this is exactly it - every situation is individual. Gina writes that 20 births later, she no longer feels the same way about a certain provider over another, free (unassisted) birth, cervical checks, and inductions.

She has found that there are no 100% guarantees when it comes to providers - not all doulas are perfectly supportive of all mothers, not all obstetricians are the devil (some are great!), not all midwives follow the Midwive's Model of Care (some do not practice patient-centered/evidence-based medicine). I would agree with this. I have heard wonderful stories of OB's who are amazing, nurses who go to lengths for their patients, and even seen some myself. I have also seen some terrible midwives (I've had some say my client isn't following the correct dilation curve, gah!). I still get excited when a client has a midwife as opposed to a physician, because on the whole I think they are still more likely to follow the Midwive's Model of Care, but every situation is individual. And you're more likely to receive excellent supportive care from a doula rather than not. But as TFB writes, "there’s no more “All” or “Always” to me anymore. What matters is a provider’s own philosophy, and the letters behind their name may not tell you what that is."

On the topic of UC (unassisted childbirth), I have to agree with Gina. I've spoken to doulas around whom I know I have to keep my mouth shut on this topic. There are some very strong supporters of UC in the natural birth community. But I have enough reasons as to why I would not birth unassisted, and also why a knowledgeable care taker should be present, to argue against it. This is just my personal opinion, but I have seen and heard about situations where a trained care provider was absolutely essential. I still think it is perfectly safe to birth at home, I just think that a midwife trained to respond to postpartum hemorrhage or use her emergency oxygen supply is more likely to save my life or the life of my baby than my partner.  I know why people do it, and I know that most of the time births are normal and low-risk. But when I'm in labor land I don't want to have to be responsible for being mentally and emotionally level-headed (which I probably couldn't be, especially if I passed out). And I don't think doulas should attend UC's either. (For more on the topic of doulas at UCs, click over to this post on Navelgazing Midwife's blog)

One point that I wholeheartedly agree with is that cervical checks in labor are almost useless! I've blogged about this before, but I will reiterate: A cervical check will not tell you how long your labor is going to be. That baby is going to come no matter how much you are dilated at a certain time. It does have several side effects: 1. disappointment and discouragement in the laboring mother, which can stall labor 2. disappointment by the medical staff, who then want to medically intervene to speed up labor in potentially unsafe ways, 3. higher risk of infection if the amniotic sac has ruptured.

There are some pros: 1. If the mother feels it will help her to know. For example, if checking before receiving an epidural can tell us whether mother can or should wait to receive one (it can stall labor before 5 cm, or if mom is about to be complete!) and 2. If the labor pattern indicates very advanced active labor but mom isn't dilated past 3 cm. This can be an indication of a problem to be worked out, for example, massaging cervical scar tissue to help the cervix dilate, or a baby being held up off the cervix by a cord and may need emergency intervention. For when you would like to know "how far along" you are, you may not even need a cervical exam - there are ways of assessing labor progress without an internal exam.

Gina makes a point in her blog post about sometimes inductions being necessary. My thoughts on this are: there are instances where some medical interventions are necessary, but they should be evidence-based and right for the patient. An induction because the mother and baby are medically at risk of eclampsia or because the mother is well past her 42 week mark are some. A truly emergency cesarean section is another.

I'd like to add one more reflective point of my own: VBAC and repeat cesarean section (RCS).
Though I believe that VBACs have been proven by scientific research to be a safe option for women, I do think that a woman has the right to make the personal decision whether to attempt a trial of labor or have a RCS. Maternity care needs to be both evidence-based and patient-centered. I fully respect a woman who weights the pros and cons of both options and makes the choice that is right for her. There are different risks for the moms and for the babies, and it is important to take into account past experiences, varying needs, and  emotions.

I agree with the way Kristen puts it:
I think you should give birth in a setting where you feel respected by your care providers.
I think you should be given every chance to have the safest, healthiest mode of birth for you and your baby.
I think you should have access to accurate and transparent information about your birth options, and that no one should use scare tactics to dissuade you from your choices.

But I also think that the way to achieve these goals is to go about things a certain way. So I do think that you should educate yourself as much as possible (take a childbirth education class, read books) and shop around for the best care provider and birth location (consider a midwife and a doula). But this is because I want you to have the very best birth, your ideal birth, and for you to not have any regrets.

I think the key to improving maternity care is not about everyone birthing the same way, but lies in removing any obstacles that impede women from having their best possible birth.

How have your views about birth changed over time, if at all? Do you agree or disagree with any of my outlook? 

4 comments:

  1. I would agree that epidurals can help get the woman to a vaginal birth, definitely.

    Also, I've stopped taking on every client and become more selective of the planned interventions I'm taking on. Like a client being induced at 39 weeks because she's "old." Not evidence based and more to do with the fact that her EDD is Christmas day. I've had to establish boundaries because a birth can be traumatic for me as a doula, especially when dealing with unnecessary interventions that the parents either don't want or seem ho-hum about. I understand that it's not my birth but damn, I'm not going to sit around for this obstetrical side show!

    I would argue that going past 42 wga is not an automatic "induce now" sign. I think that the risks associated with an induction far outweight being postdates, in my opinion. However, I probably have a more conservative view on who should be induced and I'd only vote for people with serious pre-e or HELLP syndrome or something like that. Not all the BS reasons I hear for inducction- AMA, postdates, low fluid, macrosomnia, yada yada.

    A note on VBACs. I think for primary cesarean sections every mom that is an eligible candidate should, without a choice, have a TOL. Elective primary or repeat cesarean secions are unethical in my opinion and I question the "patient choice" argument. Is it really a choice or fear? I'd schedule myself for major abdominal surgery if I was being told that my uterus was going to rupture and my baby (and myself) was going to die. I can't just walk into a general surgeons office and say I want an appendectomy in case mine goes bad. I think at the end of the day doctors need to say, no, we're not performing this major abdominal surgery on you for no medical reason.

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  2. I totally understand not wanting to take on every client - at some point, as a doula, you've got to keep your own sanity. They will find the right doula for them!

    I think as far as the VBAC issue... I think there are real risk for the baby that might outweigh the lack of risks for the mother. Knowing that they do happen (some babies are born with neurological issues due to uterine rupture), I think a mother should be able to weigh the risks. I ALSO think that ideally, all VBAC TOL's would take place in a setting with surgical delivery possible at a second's notice. I know this is not the case currently, due to the political/medico-legal climate. Maybe THEN everyone could be required to have a TOL.

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  3. The Saint Pete: do you *really* believe it's ethical to force a woman with a phobia of childbirth to go through with a vaginal birth? Because honestly, I think that kind of attitude is unethical, myself.

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  4. Wow. I find it horrifying that anyone would try to *force* someone to have a trial of labor, whether she wanted it or not. It's BS like this that makes me think that, in truth, the "natural birth" movement really doesn't give a damn about women.

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