How Not To Be THAT DOULA In A Nurses’ Mind

Dec 13, 2013 by

THAT Doula is the one the nurses roll their eyes at and don’t want to see in the labor room.  The one they aren’t certain about, the one who leaves them wondering how their patient may be negatively influenced, the one they feel oversteps her boundaries and has her own agenda – not the patient’s – in mind.  I’ve done extensive research interviews with doulas and nurses, consulted with nursing unit directors and had served as a mentor doula.  To me, the vast majority of the time these concerns arise from misunderstandings and miscommunication between nurses and doulas.

So how do we counter these negative perceptions that nurses may have about a doula when we arrive at the hospital?  (Now this is much harder when the hospital staff has had experiences with a rogue doula who behaves in these ways on a regular basis.  That may require a more direct approach.)  What I am talking about here is building your own reputation as a trustworthy doula.  Often we can’t do anything about the past, we can only begin with the next birth.  Here are best practices culled from experienced doulas and labor and delivery nurses:

  1. Smile.  Smile when you meet someone, smile when they walk into the room, smile when you walk down the hall.  Be genuinely yourself, don’t fake smile.  A person’s brain perceives a smile as welcoming and automatically changes their behavior to be more receptive towards the person smiling at them.  This is unconscious.  So shifting your behavior to be welcoming by authentically smiling can use this to your advantage.
  2. Adjust your nonverbal behavior to be welcoming and acknowledge the MCP’s presence when they come into the room or closer to the laboring mother’s personal space.  A head nod, slight shift in your shoulders or body orientation can indicate your awareness of their presence.  You can do this while not taking your attention away from the mother in her laboring, or wait until the contraction passes if needed.
  3. Introduce yourself, share a little bit about yourself and what you are there to do.  “Hi, Nancy.  My name is Amy, I’ve been a doula for 20 years off and on.  I’m here with Nick and Nora to help them with comfort measures, remind her to change positions, fetch things, and to remind Nora to speak to you and Dr. X about what is most important to her about her birth.”
  4. If needed, explain what you do not do.  “I don’t do vaginal exams or anything clinical.  I don’t speak for Nora and Nick, I just remind them when it’s a good time to discuss their wants and needs with you or the doctor and midwife.”
  5. “Wonder with” and include the nurses when they are present.  “I wonder if we might try…”  “Nora seems to be tiring, maybe a position change would be good???  What are you thinking?”  “Are you noticing Nora’s cxns slow down when her mother is in the room or is it just me?”  Nurses have been to hundreds of labors and may know coping strategies that we’ve never thought of.  It is a courtesy to ask – remembering mom is the decider.
  6. Include the nurse in the mother’s coping ritual whenever you can.  Any connection you can enhance between the mother and her nurse is good for their relationship.  It also helps the mother to feel safer and cared for.  Nurses like to provide comfort measures but their other responsibilities limit their time.
  7. Acknowledge the nurse’s rank and her territory.  If you are thinking about a big change, such as laboring in the tub or walking the unit, find the nurse and ask her before you do it.  Maybe ask her in a general way an hour or two before you make your move.  “Nora wanted to try laboring in the tub today.  Is there any reason we ought to check with you first before doing that?”  Some nurses don’t need this communication, while others feel put out when their patient is doing something unexpected.  There’s nothing like going into a patient’s room and finding her not there!   If the physician calls and the nurse is out of the loop, she looks less competent.
  8. Do simple things that make the nurse’s job easier.  Pick up the dirty laundry, offer to get her something to drink when going to the kitchen.  Imagine yourself working together on the same team and building a relationship.  You are!  You are both on this mother’s birth team along with her family members.
  9. Urge Mom to speak up verbally about what she wants to each nurse and MCP.  “I really want to avoid an epidural” or “I want an epidural but Amy is going to help me to use the tub first to see if I like it.”  “Don’t tell me to ‘push, push’.”   Get mom and her partner used to speaking up.  Get their voice in early and often.
  10. Prompt mom to speak up:  “Nora, do you want to tell the resident about your approach to pain medication?” Maybe a slower, gentler approach is better: “Hmmm, Nora, I’m wondering if you want to share what’s important to you with Dr. Y since she’s going to be involved with your care.”  You want your voice to be remembered as the one who is reminding mom, not the one who is saying the words for her.
  11. If you’ve done the prompting and mom doesn’t say anything, let it go.  It is her birth and if her vision is not happening because she isn’t saying anything then you have to let it go.  A good general guideline: “I’ll stick my neck out as far as my client does, but I won’t go farther than she does.
  12. When a medical decision needs to be made invite the nurse to stay in the room.  “ Since Nick and Nora have some time to discuss what to do next, Nancy, do you want to stay in case they have any questions?”  By inviting the nurse to stay you avoid the appearance of being manipulative or unduly influencing your clients toward other approaches than the one being initially recommended.
  13. Don’t give medical information.  Help your client to solicit that information from the medical staff.  You know what you know so that you can tell if they are getting the information they need to make a good decision.  You don’t know it so that you can say it out loud to your client.  The doula’s role is to enhance connection and communication, not be the source of medical information.  It is okay to ask leading questions IF your client has indicated she wants more information but it doesn’t seem to be forthcoming.  “Isn’t there some kind of number or score about her cervix to consider when breaking her bag?  I think Nora and I were talking about that a while ago.”
  14. Know what you know and don’t claim to know what you don’t know.  If you are unfamiliar with position changes with an epidural, say so.  “I took a workshop where getting in a kneeling or hands and knees position with an epidural was helpful in preventing posterior positioning and labor dystocia.  I haven’t done it before, but Nora would like to try it if possible.  Do you think we could work together and see if that is good for Nora and the baby?”
  15. Realize that everyone present is providing what they feel is the best care for mother and baby.  Almost all physicians, midwives and nurses are making the best recommendations possible based on their knowledge and experience while taking your client’s preferences into account.  It is the rare MCP who is misogynist or disregarding the emotional importance of childbirth.  I’m not saying that it doesn’t happen.  I am saying that making that assumption without direct experience of it does a disservice to you, your clients, and the medical staff you are working with.
  16. Repeat after me:  “It’s not your birth.  It’s not your birth.  It’s not your birth.”  Tattoo this in your memory, embroider it on the inside of your birth bag.  It’s not our birth!  Our role is to follow the woman’s lead even if it seems she is doing the opposite of what she said she wanted prior to labor.  Don’t have your own agenda for this birth or this mom.  Her birth is her life experience.  Don’t cheat her out of it just because we want it to be a different way.  Our job is to support the choices she is making now even when she may not stand up for herself or what she said she wanted earlier.
  17. Your reputation precedes you and nurses will talk about you after you leave (perhaps even while you are there).  Make sure that this nurse has good things to say about you – or at least nothing specifically bad.  It may take more than one birth for positive feedback about you to circulate but it’s worth it.  Hopefully you will experience greater satisfaction in your relationships with medical staff by following these strategies too.
  18. Nurses have personalities, struggles with coworkers, worries, and families waiting for them.  In other words, they are whole people.  Show respect for them and concern for their needs.  An approach that works with Nurse Nancy won’t work with Nurse Abby.  A large factor in your success as a doula is your ability to pay attention to other’s cues and adapt your behavior to get along successfully with them.  Our job is complex because we have to do this with our client, her family, her care providers and members of the nursing staff – simultaneously!!

These are advanced communication strategies that seem deceptively simple.  It takes courage to change even when behaving in a way that is natural to us isn’t getting the results we want.   All of them are ways of being at a birth that highly effective doulas practice and that labor and delivery nurses said they appreciate.  My hope is that they will help you find increased satisfaction and harmony in this critical aspect of doulaing.

 

Here is a pdf copy of this post: How not to be THAT DOULA in a Nurse’s Mind

12 Comments

  1. I love this! Fantastic advice ! Thank you!

  2. liz

    Very good post. I would like to say though, regarding #12, that as a Doula I’m not big on inviting the hospital staff (unless the parents specifically request) to stay in the room when the parents are discussing a transition or decision in their birth. I think it is very appropriate and should be respected by the nurse and other care providers, without the appearance of manipulation, for the family to be allotted the appropriate amount of private time to discuss options and gather questions without the presence of hospital staff. I also ask if they would like time to discuss without my presence. Keeping the communication open with the nurses that we will all regroup in a bit because we would love to ask her some questions and get her opinions. Every time this has been put into practice the nurses have been totally respectful and helpful. :)

    AWESOME post and I am looking forward to sharing!!!! Great work!

    Liz

    • Amy Gilliland

      Great! I have done that too when I was able to disengage from the support ritual. Very good points – thank you!

  3. I would add, when you are leaving after mom and baby (and dad!) are settled postpartum, go and thank the nurses you worked with. Shake their hands and/or hug them and thank them for a wonderful experience, or an instructive one, or for being so helpful to the parents, or being a great advocate or being funny – pick something that stood out from your experience with that nurse and mention it with sincere thanks.

    Secondly, if you learned something new or were allowed to participate in something you haven’t before, thank the nurse sincerely for sharing with you and for helping you learn. For example, I was at a birth where the nurse tried a couple of interesting pushing/positioning techniques that were incredibly effective when the baby was having trouble coming under the pubic bone. I’d never heard of them before and was genuinely thankful for the nurse sharing those. I thanked her for giving me a “masterclass”. A month later, I suggested one of those two techniques at a birth at the same hospital and it was instantly effective. I attributed it to that nurse and when bumping into her later, thanked her again. I’ve also had a nurse advocate to let me stay during an epidural placement and thanked her later for treating me not like one of the family’s two designated support people but as if I were part of the health care team. I thanked her for that.

  4. Thanks for writing this! We did not have doulas when I was a L&D nurse, but I understand the issues that go on between the professions. I think it’s a great list… with a couple hesitations/reactions that arose in reading it. If a doula told me:”I don’t do vag exams..” my distrust would rise … Why is that something she needs to say?….of course she doesn’t do vag exams.. It would not have crossed my mind, but now that it has, I’d be more nervous of her. #12: Inviting the nurse to stay in case they have questions.. I”d make the invitation more a request… Rather than “do you want to stay?” .. maybe saying “Would You Be Able to stay” sounds more like a respect for nurses wisdom, vs trying to avoid the nurse being offended, which is what comes up more for me in the first way.
    Minor things, but just noticing where my nurse self reacts!
    Wonderful job of pulling this together. I’ll see about sharing this at the Getting Back in Touch: Integrative Care in Birthing Conference I’m helping organize in Maine 2014.

    • Amy Gilliland

      Thanks Leslie! In my experience, nurses who are wary of doulas are concerned about VE’s. So that is why I mentioned it. Perhaps it is in how it is said…also it was an example of something a doula might say not a script of exactly what to say…Thank you for the feedback!
      I’m always happy to travel and enjoy speaking at nursing conferences too if you’d like to have me.

  5. Wonderful..all doulas should read this. Thanks for writing it. kate

  6. Andrea Little Mason, Ed.D.

    I appreciated you associating these advanced communication strategies to doula work. I am sure this post will be instructive to many. :)

  7. doula in the trenches

    Thanks for this post!!! This is the encouraging doula wisdom I had subscribed for quite a while back. To be honest, I had nearly given up on this blog over all the certification discussion!

    • Amy Gilliland

      Glad you’re back – I felt kind of bogged down by then end of the cert discussion myself. But I felt an obligation to slog through all my findings and responses I’d gathered. Other people really enjoyed that I put that whole dialogue into perspective though. Thanks for the pat on the back!

  8. Yes, Yes, YES. Big FAT YES!!!!!! Thanks so much for what you do. I can’t tell you how many doctors and nurses have told me that the doulas they meet are unfriendly to them and RUDE. They have actually said the doula wouldn’t look at them, or when she did, she gave them a dirty look. Unbelieveable. I am really frightened.

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