So I sent a message out to my doula list today…

And here is what it said:

I find it interesting that as doulas, we advocate and insist that doctors use evidence-based practice and not practice based on the fact that, say, they once witnessed a VBAC that ended in uterine rupture and are therefore worried about all future VBACS (when in fact, the evidence shows that the risk is small and VBAC is actually safer for most women). However, I rarely see evidence-based advice passed back and forth on this list; it’s mostly anecdotal.  I would love to see more evidence-based discussion and transfer of information here. When anyone asks me a question about pregnancy or labor, I try to present the evidence to them so that they can make the decision for themselves and not tell them what I think the best decision is. Just a thought.

I am eagerly waiting the response. We’ll see what happens.

A Plea to Other Doulas

(Cross Posted from Nurtured Moms)

What is the role of a doula? Lately I’ve been considering it carefully. There are a couple of things precipitated this reflection. First was the lukewarm (at best) reaction of a friend of mine — a labor and delivery nurse —  to the news that I was becoming a doula. I also recently witnessed and participated in email/online discussions on the matter. Finally, as I attended a “professionalism” training course for the doula volunteer program I’m joining, it all started to crystallize for me.

Why would a labor and delivery nurse dislike the idea of a doula? I know she is committed to helping moms have both a healthy baby and an excellent birth experience. She became an L&D nurse because she loves L&D! I think part of the problem is that many doulas see themselves as some kind of soldier. An advocate of natural birth, but to the extreme. Any intervention is considered some sort of a failure and a “bad birth.” Something to go back to the email list and deconstruct: “How could this have happened? Where did I go wrong?” I know doulas who will reject a client who who wants an epidural or an induction. Some doulas even feel it is appropriate to physically block medical personnel from their clients, unhook monitors, or take out IV’s in the name of letting nature take its course.

I don’t believe a doula is a “Birth Warrior,” in the sense that we are fighting to change the way birth is done around the world as we work with each individual client. As a doula, it is not my responsibility to make medical decisions for my client or to interfere with medical procedures she has consented to, no matter what I feel about that particular procedure. I can make sure she understands what a decision means and how it might affect her. I can educate her, and I can remind her of her goals. However, it is her responsibility to make her own decisions and interact with her doctor, midwife and nurse about those decisions. Once the decision is made, it is my job to support my client. I am not her voice, I am her support. It is just as paternalistic for me to tell my client that I know what the best decision is for her as it is for any doctor to do the same.

I would encourage any doula to read this article in the New York Times.  Here is the meat of the story:

At first, Ms. Myers, now a 36-year-old mother of two in Glencoe, Ill., was thrilled with her doula, who doubled as a prenatal massage therapist. “She was earthy yet grounded, and really knowledgeable,” she said.
Then labor began — and went on and on — and Ms. Myers’s opinion took a nose dive. Though the doctor recommended that Ms. Myers receive intravenous fluids to hydrate her, the doula, eager to avoid medical intervention, insisted that Ms. Myers ignore the suggestion, causing her contractions to spike.
Then “she urged my husband and me to take a shower to ease the pain,” Ms. Myers said. “I told her I didn’t want to, but she was adamant.”
Dripping wet, freezing and in bone-shattering pain, Ms. Myers said she seethed in silence. When she ultimately chose an epidural, her doula walked out. “She was so set on my having a natural birth, she offended me, she offended the nursing staff, she offended my O.B.,” Ms. Myers said.

Do you think Ms. Myers wants to work with a doula again? How about her OB or her nurse? How do you think they treated the next client with a doula who came to them? What about the myriad of people who have read this article in the New York Times? The professional reputation of all of us has been damaged by this one overzealous woman, and it will probably take thousands of positive interactions to make up for the damage done. Not only that, but there are more doulas out there just like the one described here. I know them.

Activism has it’s place. I think that as doulas, we should be involved in birth activism — we need to focus on changing the laws in our areas to favor women and their access to birth choices. We need to build relationships with doctors so that they can see that we offer a valuable service and enable more women have access to doulas.  If we witness our client being assaulted, we should call 911 at that moment and report it, or at the very least encourage our client to do so. These are the kinds of things that effect actual change. However, when it comes to medical decisions and care in one specific case, it is not our responsibility or within our scope of practice to make them for our clients. I believe if we focus on empowerment and education, we will be more successful in our attempts to expand access to the myriad of birth choices we want our clients to have, then when we speak with vitriol and act with superiority.

Epidural Anesthesia: Wading Through the Insanity

(cross post from Nurtured Moms)

“I loved my epidural. It gave me the opportunity to sleep for awhile until I had to push. I was well rested and it made the whole experience great, IMO.”

“If you have an epidural, you’re WAY more likely to have a c-section. NO THANKS!”

“It was the best decision I made, no pain!!”

“I decided from the moment I became pregnant, that I would have an epi! I did it … and it was FANTASTIC!!!”

“It’s worth factoring into birth plans that at least 25% of epidurals have negative side effects, many of them very serious. It’s really only designed to be used in an emergency situation when the benefits outwiegh [sic] the many risks. Physiological childbirth isn’t an emergency, it’s what we’re designed for.”

“Millions of women have had epidurals without a problem. Obviously it’s pretty safe!”

If you check out any online birth and labor forum, the subject of pain relief and birth will eventually come up.  All of the above are actual comments I cut and pasted directly from online discussions about epidurals. Women love to compare stories and ask for advice when it comes to pregnancy and childbirth. Unfortunately, online — and offline, for that matter — discussions are fraught with misinformation and “anecdata.”  Not only that, but while I was researching for this article, I found a lot of online info that was out-of-date, dismissive of the risks, and scare tactics using studies from the seventies and eighties or half-truths. So what’s the real story on epidurals? There is plenty of recent evidence-based information if you know where to find it. I’ve tried to compile the most relevant numbers, statistics, and links to scientific information with as little commentary and snide remarks as possible, so that you can decide for yourself what you think about epidurals. For the record, I have a mild bias towards natural birth, but I also believe that it is wonderful that modern medicine has provided labor pain relief for those women who want or need it.

What IS an epidural, anyway?

What is the evidence related to epidural use in labor and delivery?

What are the risks of an epidural?

What are the benefits of an epidural?

The choice to have intervention like an epidural is entirely up to the woman who is giving birth (and it’s wonderful that women have these choices).  With choice, however, comes the importance of ensuring she is fully informed, and the knowledge that she takes full responsibility for any outcomes of her choices. As such, comprehensive research is essential, and allows a fully apprised decision. I hope this article is a good resource for anyone seeking to be informed!

Major sources (all sources are linked in text)