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