The Doulas Have Arrived! Nurses, What Does This Mean For You?

Feb 9, 2014 by

Dear Nurse,

When doulas move into a new area, nurses are often skeptical and hesitant rather than welcoming.  This is a normal reaction to change especially when you are uncertain about how it is going to affect you – and how you do your job.  Here is a list written by an experienced doula trainer that might be helpful for you:

  1. Professional doulas want to work with you to help a laboring mother’s needs get met.  She views you as an important ally who has some of the same objectives and priorities.
  2. The doula’s goal is to remind their client to tell you and her physician or midwife what is most important to her about her birth.  She may have listed her preferences on a one page birth plan or may only state them verbally.
  3. Professional doulas do not have any agenda for a “natural” birth.  Every woman benefits from doula support – even mothers planning an epidural or cesarean section.  She and her family can benefit from the added nurturing, reminders they can discuss options, and extra hands that a professional doula can provide.  A doula birth is a supported birth.
  4. Professional doulas are familiar with the research evidence and best practices for maternal and fetal health.  Doula clients tend to also be familiar with this information – which is why they hire a doula.  Because of this, patients with a doula may make more requests than an uninformed patient.  Some of these requests may be a part of hospital protocols even though the obstetrical unit’s culture does not usually promote them.  Some examples:
  • No routine amniotomy
  • Intermittent fetal monitoring
  • Freedom to choose second stage positions outside of bed
  • Hands and knees, kneeling and semi-sitting positions with an epidural
  • Delayed cord clamping
  • Baby’s naked body on mom’s naked body immediately after birth and not removing it for 90 minutes or more
  • Delaying routine newborn procedures (not health assessments) for 90 minutes or more
  • Newborn exam on mother’s body or her bed
  • Weighing and bathing of baby in the patient’s room
  1. When patients prefer a cooperative decision making relationship with their care provider, they usually hire a doula.  The doula will help to remind them to ask questions about their care.  This interaction style may be rare in some obstetrical settings.  Rather than having their physician autocratically making decisions, these patients expect to be consulted and give explicit consent for each intervention.  With these patients, the doula may ask if the mother and her partner have any questions about a proposed intervention.  The ensuing discussion about benefits, risks, and options may be seen as an interruption or a delay.  However, involvement with decision making has been shown to increase patient satisfaction, birth satisfaction, lower anxiety, lessen the incidence of postpartum depression and prevent post traumatic stress disorder due to a traumatic birth.  This has been repeatedly shown in the nursing literature to be more important than complications, length of labor, or location of birth to short and long term maternal well being.
  2. In order to facilitate involvement in decision making, a doula may tell the patient about an unannounced intervention the physician is about to do. This way the mother may give explicit consent or ask for clarification.  This may be seen as an interruption by the nurse or physician but this is what a doula accompanied patient expects her doula to do.
  3. Despite these interruptions to the usual flow of care, the professional birth doula is your ally.  She knows the patient and can help you to get to know her too.  She will observe almost every contraction and can keep you informed of any issues the mother has or adverse symptoms shy mothers may keep to themselves.  They help mothers to stay focused.
  4. With a 60-80% epidural rate in most hospitals, nurses do not see many unmedicated labors. Doulas have been trained in normal physiologic birth, as defined by the American College of Nurse Midwives (ACNM).  Mothers without pain medication may become louder and listen to their bodies’ urges to move around as labor intensifies.  When mothers are coping well they are calm between contractions.   The doula will help the mother to continue her coping ritual – which may become louder and more intense as labor progresses.

Three Clinical Recommendations:

When you are introduced to the doula, ask her about her training and experience.   Professional doulas are usually excited to tell you about their organization and background.  If she has not taken a training, then she is the client’s friend who is doulaing her. She is not a professional, so none of the descriptions in this essay apply.  The “doula” friend may act in ways that a professional would not do, such as speaking for the mother, touching you or the physician inappropriately, arguing with you, giving medical advice or telling the mother what to do.  These are NOT in the scope of practice of a professional doula.   If she is doing these things and has been trained, she is considered a rogue doula, behaving outside the circle of professional practice and ruining our reputation.  We hope she goes away even more than you do.

New doulas may make beginner mistakes.  There are more new doulas than experienced ones.  This is a challenging profession and many promising new doulas find it is not a good lifestyle fit.  Please be patient with the beginning doula and help her to learn how to treat you.  She wants to do her best to get along with you while helping her client to have the best birth possible.  She may ask more questions about procedures and provider preferences until she becomes familiar with your facility.

Labor and birth are changing due to the doula’s influence.  But this is not necessarily a bad thing.  Nurses are learning alternative approaches in non-pharmacological pain management and positioning techniques to rotate malpositioned babies.  They are relearning the satisfaction of emotional connection to a patient that the doula helps to facilitate.  They are seeing normal physiologic birth happen in their facility (even though it may require suspension of usual interventions).  But most of all, because of nurses and doulas working together, mothers and babies are having emotionally healthy outcomes as well as physically healthy ones.

Here is a pdf copy of this post: The Doulas Have Arrived

12 Comments

  1. Heather

    Love this. Thank you!

  2. Sad Nurse :/

    So I will preface by saying I am a L&D Nurse. I’m an L&D nurse who has helped support and empower moms for over a decade. I’m an L&D nurse who chose to go to a midwife for her births. With my midwife and husband’s support, I was able to have natural births. I wanted to wait for labor, not have interventions, no epis, skin to skin, to breastfeed, and to have my baby with me at all times.

    I’ve worked in multiple L&D’s in the country due to moving and have worked with MANY other nurses who chose similar paths of seeking midwifery care. These nurses were always happy to work with moms desiring low intervention births.

    When a mom has a doula, I am always happy b/c I know that she will be surrounded with an extra level of support. Every mother deserves to be in a protective bubble of love and support.

    Having said all this — I find this article really upsetting on many levels. Maybe it is because I am someone who has always tried to connect with everyone in the room – regardless of your background. Because part of what I learned in nursing school was that the support people in the room of any patient (we actually learned client in school!) b/c it will only help them, to involve partners and support people in care, to treat everyone holistically and provide family centered care. Part of what you learn in nursing school is to guide your mom, patient, client – to ask questions, to be involved in their care, and to empower them to make decisions. It is ingrained to empower your patient, to be their voice when they need it and to help educate when needed.

    Many of the things that you listed as not being typical culture:
    -skin to skin
    -freedom of movement
    -intermittent monitoring
    -rooming in
    -passive second stage
    -open glottis pushing
    -position changes in second stage

    These are all things that the governing body for OB nurses has written a multitude of position statements supporting and stating that they should be the norm. The name of the organization is AWHONN (if you have heard of them and are familiar, forgive me…. since they aren’t mentioned I am bringing it up)- please look at their website and all of their statements. It may be refreshing to you as this is the equivalent to ACOG for OB’s or ACNM for CNM’s.

    If nurses aren’t practicing this way then they that aren’t following the current evidence and body of knowledge that they ought to be. I can’t speak to why they aren’t… and that clearly is a deficit… perhaps they are in a system that won’t support it. Or they are unaware. ? I don’t know. But every nurse has a duty to keep up with current recommendations.

    I think that sometimes there are just less than ideal nurses, just like there are less than perfect doctors, and midwives, and sometimes as i have seen referenced on here as “rogue doulas”

    I read your blog post about how to connect with your nurse and I thought it was great and know that you are coming from a place of good intent. I guess I’m asking for respect b/c I felt very disrespected reading this… not respect in the sense that the nurses should call every shot or not involve the patient or anything like that… just respect as a human being who is also trying to do the very best thing they know for that mom in labor…. and doulas deserve the same respect…and if you all aren’t getting it – i apologize b/c you should.

    I’m sorry to write with negativity but I felt like I had to get it out there. I think the hardest part for me to read was the title: flip the wording around and see how this would feel to you”

    “The Doctor Has Arrived, Doulas What this Means for you” or “The Nurse has arrived, Doulas what this means for you”. And then the part:
    “When doulas move into a new area, nurses are often skeptical and hesitant rather than welcoming. This is a normal reaction to change especially when you are uncertain about how it is going to affect you – and how you do your job. Here is a list written by an experienced doula trainer that might be helpful for you:”

    It already sounds territorial. I asked my partner to read it and didn’t offer my opinion on it… complete agreement.

    I think it would be received a whole lot better if there wasn’t negativity in the very first sentence.

    My suggestion:
    Title: not sure – but please change it….
    Dear Nurse,
    We haven’t worked together and I know you are here to help support and keep every mom and baby safe. We are in this together as a team. Since we have not worked together often, I thought that this is a list written by an experienced doula trainer may help:

    • Amy Gilliland

      Dear Sad Nurse,
      I am sad too! I wish all nurses had your open attitude and practiced according to the best evidence. Many nurses think that what is happening in their facility is what is happening everywhere, even when they are still doing things the same way they did ten years ago. Many of the things you list as commonplace are NOT common at all. Even when they are written as the hospital’s protocols following the best evidence, that does not mean they are followed. This is my experience working with nurses, nurse-midwives and physicians from a number of hospitals, and asking them directly about practices. There are a variety of reasons why, which would be a whole other blog post.

      This piece was written in response to several recent interactions I had (or were described to me) where nurses were feeling apprehensive about the doulas in their area, many of whom were new. They were skeptical that there can be any benefits to having a doula in the labor room and they do not know what to expect. Many nurses only hear bad stories or comments about doulas. I wanted to give these doulas a tool to use in these situations. Since it doesn’t fit your experience or apply to what you know to be true, then it isn’t useful to you. I’m glad the other post was useful to you!

      In the end it depends a lot on the culture of the unit – what expectations and attitudes are communicated to nurses. Some are very “high touch”, nurses are encouraged to spend a lot of time in patient’s rooms, they practice skin to skin for 90 minutes or more (which sounds like your facility). Many others discourage time in patient’s rooms, prefer mothers to have epidurals, and will give the mother the baby after birth, but not skin to skin, and maybe for only ten or fifteen minutes. While they may be members of AWHONN there can still be an attitude that “we know what’s best, this is what works for us” even when it goes against evidence based practice or position papers. (There is some great nursing research on why L&D units have such a difficult time changing to follow evidence based practice, including “diffusion of innovation” theory.)

      (I am familiar with AWHONN. Back in the 1990’s when I was on the board of directors of DONA I worked alongside their president in writing the CIMS document on mother-friendly birth, and I’ve been published in JOGNN.)

      Thank you so much for commenting so sincerely and bringing up a different point of view.

      Amy

  3. kim

    I am a labor and delivery nurse and I have to say I am so proud of the way our hospital is changing I also have been trained as a doula, I want everyone to know and make sure that women understand most labor and delivery nurses are not your enemy and want what you want but unfortunately we are hindered by policy and procedure but we do fight for you, I wish that birthing moms who feel strongly about having as much a natural birth as they can didn’t come in with this chip on their shoulder and feel they have to start off fighting, it is so hard to make them realize I am on their side and will fight for them! it is so great when they realize this because the relationship truly begins and we try together as a team to make it a great experience! I love when pts have trained Doulas I truly feel this helps the mom and dad to get through such an amazing journey and when you put the Nurse, Doula and family together as a unit we are non stoppable lol! I LOVE MY JOB and I LOVE working with familys in one of the most exciting times of their life!

  4. MotherWit Doula Lesley Everest I love it because it covers so many questions, preempts the ruffled feathers of territorial staff feelings, and also gracefully holds doulas to task in terms of their approach with a staff member Newer nurses I havent worked with often are surprised how with one client I will be supporting her howling in transition then for another will be super enthusiastic about a clients chosen 4-5cm epidural. Then they realize OH, you tailor your care with respect to your clients wishes! My biggest challenge with staff is their assuming doulas are puppet masters, whispering demands into their ears to further our own agendas. This open letter puts the kibosh on that and illuminates the client’s agency. May it be widely read. Thank you, Amy!

  5. Excellent! Shared on Facebook – I like what you say about patient vs. birthing woman, both sides make sense!

  6. liz

    Love! Love! Love!!!!!!!

  7. This is awesome! Thank you for sharing!

  8. Amy Gilliland

    Cynthea Denise shared this on Facebook: Amy, thank you so much for sharing the letter. It is so clearly and beautifully written. I will however be so very glad when a birthing woman is no longer referred to as a ‘patient’…..the word patient psychologically belittles the mother in a way that is very subtle but without a doubt puts her in a position that implies less than…..YES this may be changing, and I feel it is important to begin to clearly CHOOSE words that describe the mother as the BIRTHING WOMAN and call BIRTH….as it is A PROCESS…..Thank you.

    My response: Hi Cynthea – I think it is important to enter the nurse’s world and use the language she is familiar with. When people are anxious, they become suspect of anything different and can shut down. So writing in language that helps them feel safe is part of the process.

    • Julieann

      Amy,
      As a labor and delivery RN and as a doula this is offensive. Many labor and delivery nurses are now becoming Doulas, inviting and embracing Doulas. This article that you have written however is offensive and destructive. This article further puts a divide between health care professionals and Doulas which is bad for the client and exactly what we are trying to prevent.

      Trying to promote the profession of Doulas by degrading and discounting the profession of nursing is not only unprofessional but it degrades the professionalism of Doulas everywhere.

      As a certified medical legal consultant in will tell you in have seen many new cases were Doulas ate being sued by physician’s and hospitals and even I some cases patients. Doulas need to realize their scope of practice before this further gets out for hand as the doula profession is currently being raked through the mud as of 2014 and instead of embracing Doulas now hospitals are trying to find ways to forbid by law doulas from attending births.

      THIS IS. AGAINST THE VERY PURPOSE WE AS DOULAS EXIST.

      It is articles such as this that are not from a place of research that further this divide. While I understand as a doula you want your voice heard, this article which is borderline bullying is no way of going about it.

      Being a doula does not require you to be a bully.

      I think a little more research and a lot of discernment will take you a long way.

      • Amy Gilliland

        I find it very interesting that a few vocal nurses are very offended by this post and the majority are relieved that I’ve written it. They take it as a tool to discuss with their peers. I notice you mention you’re a nurse, a medical legal consultant and a doula. The actions described here are all in the doula’s scope of practice. This was written to help clarify roles and provide background on the doula’s motivations. I’m not quite sure who I’m bullying – the nurse?? I’m just describing the reality of obstetrical care in many places, not all.
        As I’ve said before, if you work in a community where mothers are routinely consulted in each medical decision and doulas and nurses already get along then this post does not apply to you. However for most doulas and nurses, that is not the reality. Neither is physiologic birth or evidence based care.

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