A recent analysis of the randomized clinical trials on the effect of social
support during labour on perinatal outcome concluded: "It would appear that
continuous support during labour is an essential ingredient of the labour that
has unfortunately been left out when maternity care moved from home to hospital
in the early 1930s. Randomised trials of continuous emotional and physical support
during labour have resulted in multiple benefits, which include a shorter labour,
significantly less medication and fewer medical interventions, including caesarean
section, forceps, and epidural anasthaesia" (Klaus et al. 1992). The authors
point out other benefits: "They [doulas} have also been associated with positive
social outcomes such as decreased maternal anxiety and depression, increased breastfeeding
and increased satisfaction with interpersonal relations with partners."
Using a doula is another example of simple, appropriate technology which can
save money. It has been estimated that if every woman in the United States had
a supportive woman with her continuously throughout labour, the reduction in interventions
such as caesarean sections and epidurals would reduce maternity care costs by
more than two billion dollars (Klaus et al. 1992).
- Marsden Wagner, Pursuing the Birth Machine, Ace Graphics 1994
Reference: Klaus, M., Kennell J., Berkowitz G., & Klaus P. 1992,
"Maternal assistance and support in labour: father, nurse, midwife or doula?",
Clinical Consultations in Obstet and Gyn, (4)4, pp. 211-217.
Day Jobs for Doulas
(Read the fascinating full article, written by doula extraordinaire Sue LaLeike,
Birthkit Issue No. 23)
- Arts and crafts
- Bookkeeping at home
- Part-time research assistant
- Pet care
- CPR instructor
- Postpartum doula
- County fair worker
- School van or bus driver
- Cook (private for friends, etc.)
- Silk flower designer
- Ski patrol
- Farm worker
- Substitute teaching
- Fitness trainer/teacher
- Healing touch therapist
- Homeschool workshops
- Web site designer
- Lawn-care service
- Word processing
- Medical transcription
- Workshop presentations
- Music lessons
- Yoga instructor
The reason birth doulas do not provide any clinical care is twofold. The philosophical
objection to providing clinical care is that when a labor support person "crosses
the line" and checks heart tones, blood pressure or cervical dilation, she
takes on a different role to the woman and a different level of responsibility
for the birth. By not providing clinical care we leave the medical and clinical
responsibility with the client and her care provider and are better able to focus
on the emotional needs of the client. This is a two-edged sword. It is freeing
not to take responsibility for the life of the baby and the mother, and allows
us to stay with the woman, talking to her, explaining to her, if problems do arise.
On the other hand, my clients go to the hospital a couple of hours sooner than
they might if I were doing vaginal checks. It is a two-edged sword professionally
as well. On one hand, caregivers are less threatened by my presence when they
learn that I'm leaving the clinical duties to them. On the other hand, my opinion
weighs less with them, I believe, than if I had the weight of several years of
formal training behind me.
There are equally compelling arguments for labor support providers to provide
basic clinical care, by which I mean cervical exams, fetal heart tones and blood
pressure. The first argument is that having those skills means it is safer for
the mom to labor longer at home. This is absolutely true. In my doula practice,
I go to my clients' homes to labor with them but generally go very early in labor
when they would not be in a hospital anyway. Most of my clients get to the hospital
at three centimeters dilation, and I've usually been with them for a few hours
before they go in. I would like to see them stay home longer. Having the exam
skills would make it possible for me to help them do that but I would also take
on a much greater level of responsibility for their care and a greater liability.
Since it is not my goal to be a midwife and I'm not really interested in performing
clinical skills, I provide them with emotional and physical support and my clients
retain the responsibility for the decision-making. I watch, look, listen, and
give them feedback on what I'm seeing. They make the call.
- Jennifer Rosenberg, "From Doulas to Monitrices: Differing Philosophies
of Labor Support" in Paths
to Becoming a Midwife: Getting an Education, a Midwifery Today book, 1998
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Question of the Week
There is some question in my community about whether not suturing a tear compromises
the integrity of the pelvic floor. Can anyone with experience give me some feedback,
including your experience(s), on this? I have always felt allowing the tear to
heal naturally without suturing was best but this has been debated recently.
- Tara King
Send your responses to:
Question of the Week Responses
Q: I have a student (Bradley) with a fibroid so large it is causing her great pain. She is 18 weeks and was recently hospitalized for it. It was recommended that she quit work for a while. It is located on the left side of her uterus. She desires more information on fibroids, and other than Anne Frye's book, Holistic Midwifery, I don't seem to have anything more for her. Does anyone out there have any information? She wishes to do things as naturally as possible, but understands some of her choices may be limited.
- Amy V. Haas, BCCE
A: I attended a birth some years ago. The client was a doctor and was
booked for an elective c-section (she'd had one for her first) for a fibroid that
was shown to be blocking the lower segment of the uterus. We talked, and we talked
and we talked. In time, she decided to go for a vaginal birth in hospital. We
talked and we talked some more. Further down the track, she commented how every
time she saw me, no matter what the circumstances, births seemed to turn out just
fine. When she saw the obstetrician, all she heard was how things went wrong and
how the ob had saved the day. We talked some more. Then on the day she went into
labour she called me. "The only time I feel safe is when I am with you. The
only place I can be with you is at home." So this woman, previously strongly
opposed to homebirth, gave birth to her beautiful 10-pound daughter--at home.
Where was the fibroid? I don't know. Gone.
- Vicki Chan
A: Dr. Christiane Northrup, in her terrific book Women's Bodies, Women's
Wisdom, talks about the impact of dairy products on fibroids. Perhaps this woman
should try eliminating dairy from her life for a month and see what happens.
- Nikki Lee, RN, MSN, mother of 2, IBCLC, CIMI
Related question: I have a friend who has fibroids. A year or so ago
a myomectomy was performed because she had one that was about the size of a lemon.
Now she is pregnant. Her doctor saw the report and said there's no way she will
ever deliver vaginally or be able to go through labor because her uterus would
split, and you know the rest. I have just started researching this. It seems that
the uterus after a myomectomy (hope I'm getting that word right) is not as stable
as after a VBAC, so it is more dangerous for the mom and baby. Does anyone have
experience with this? Are the reports of danger doctor-based and not on trials
of labor? Also, any natural remedies that can help reduce fibroids? She's young
but has had history of fibroids and has them now, but she is in her 17th week
and things look pretty good.
In Celebration of Doulas
I have been a doula for a little over three years and 117 babies ago. There
is nothing like seeing a woman become empowered through the birthing experience.
I consider myself a birthguide--only there if she ventures from the path and needs
help returning to it. I give her my heart, my ears to listen to her fears, my
hands to touch, and my eyes to help her refocus. I don't mind the long hours,
the sleepless days and nights. The gift of the birth is what makes it so wonderful!
Most of my clients stay in touch forever! I am beginning to really do a lot of
repeat clients now--it's such a compliment to be invited back again!
I waited till my kids were all grown to become involved in this and that has been
a blessing too--I am not splitting my attention. This is wonderfully rewarding
- Teresa Howard, CD(DONA), CLD
I trained with ALACE to be a labor assistant/doula one year ago and have been
blessed to assist in 10 births as a doula and 13 births as a midwife apprentice/
assistant. I am helping birthing women and their families--I know this deep down
in my heart. I am truly helping the mothers believe in themselves (because I believe
in them), and I am helping the fathers as a calming, trusting, supportive force
for them also. Yet at the same time, these men and women and babies are teaching
me so much more than they will ever know. Each birth situation is so unique and
because these women are allowing me to help them, I am truly gaining the experience
I need to further educate myself and help others. What an incredible gift I am
- Lori Bilbrey, ALACE doula
MAY IS DOULA MONTH! Doulas, please submit a one-paragraph philosophy
of doula practice to E-News, or a one-paragraph description of why your work is
important, or aspiring doulas, submit a one-paragraph "Why I Want to be a
Doula" description to E-News. Be succinct, feel free to cite studies and
experience, or be poetic, speak from the heart! We will publish as many as we
can fit throughout the month of May!
Know a strong woman? Helping empower one? If you haven't already done so, please
forward this issue of Midwifery Today E-News to one or two of your friends or
business associates. Thanks so much!
I am an Italian midwifery student. I am looking for teaching material on perinatal
death and on parents' grief. Can you help me?
Reply to: firstname.lastname@example.org
To the reader who inquired about midwifery care in Switzerland [Issue 3:19]:
Tell your friend to call at the "Arcade sages-femmes," Blvd Carl-Vogt
85, 1205 Genève, tel. 022 320 55 22. The Arcade is a collective of independent
midwives who do everything from prenatal care, homebirth to postnatal care.
- Gerlinde Michel
INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to
"International Connections." We're here to help you!
Thank you so much for including international doula month as part of E-News
this month. I am a recently trained doula struggling to get anyone to talk with
me. It has been very frustrating (especially this month) in this area and I was
beginning to feel very discouraged. I have tried to reach several doulas in the
area many times and have not received any responses from them, and many midwives
in the area are not supportive of doulas. It was encouraging to see that people
do think about us and still feel there is a need for doulas in birth.
In response to questions about evening primrose oil (EPO), red raspberry, and
peppermint oil [Issue 3:19]:
I have previously been told that evening primrose oil is not safe to be taken
before 36 weeks because it is a prostaglandin and may cause preterm labor. I used
it for four weeks before delivery (I went to 42 weeks) both intracervically and
orally. No labor started. As for the red raspberry leaf capsules (tea is less
potent), I have also heard it is not to be taken before 36 weeks because it is
a uterine stimulant and could cause preterm labor or other complications. I have
also read that peppermint oil is to be avoided during pregnancy, but can't remember
why. I think preterm labor was one reason.
- M. Farney, RN
Some medical and popular media make reference to raspberry leaf tea as something
to avoid during pregnancy for risk of miscarriage. This notion stems from a study
conducted in 1954 where fractions were isolated from Rubus sp. and applied in
vitro to the uterine tissues of guinea pigs and frogs. Researchers discovered
such things as one fraction acted as a spasmolytic whereas another caused uterine
Herein lies the risk of isolating the parts of a whole. When used as a whole
plant, neither action is exacerbated and the herb is deemed safe. If a mother
is prone to miscarriages she may feel safer avoiding raspberry until the third
trimester. But this is an herb with centuries of safe use behind it, so there
is usually little cause for concern. As a prenatal herbalist I spent a great deal
of time researching this topic and came to the conclusion that its use is positively
safe. Correlation with spotting and miscarriages were also sketchy and mostly
unfounded, although it is my understanding that in the UK its use is contraindicated
until the last trimester.
- Stacelynn Caughlan, Cl.N., C.H.
I don't have scientific info on EPO, just stories passed from mother to mother.
Every woman swears that EPO was what made her labor so "easy." It helps
with the dilation and effacement of the cervix. I walked into L&D 7 cm dilated
without much pain to that point (transition was another story!). I started taking
3 tablets in week 35, 4 in week 36, 5 in week 37, etc. (though I don't think I
ever could take more than 6--too many pills for me). I did not take it before
35 weeks but I did take flax or omega-3 rich oils throughout my pregnancy. Why
is the pharmacist making suggestions? Sounds to me like he is practicing medicine.
- Colleen Morris
I took EPO orally since the very beginning of pregnancy with no side effects
and great relief from pelvic/muscular and ligament pain due to my growing uterus.
I never experienced any of the dangerous side effects listed for pregnancy. I
took at least 2 g/day (4 caplets of 500 mg each) and more during uterine growth
Ask your pharmacist to *provide you* with the reasons for his advice.
- Marypascal Beauregard
I had a patient with rectal prolapse (longstanding, since sexual abuse as a
teen) having her first baby. She consulted a surgeon who said he could not do
anything for her while pregnant. She labored beautifully (in hospital, no IV,
intermittent monitoring, out of bed). When it came time for pushing, as she and
I had agreed upon before labor, I provided counterpressure (while using hot compresses
for the perineum), and while I was gloving up the RN provided the counterpressure
(a nurse who does not usually like to work with midwives because she loves high-tech,
low-touch, epiduralized births). The mom had a wonderful, controlled delivery
that resulted in an intact perineum, no prolapse, and a great amount of psychological
- Debi Lesnick, CNM
To Mandi, who inquired about studying to be a midwife [Issue 3:19]: I am also
going to become a midwife. That's why I enrolled in AAMI, a home study course.
You can study at your pace, their guidance and support is excellent, and you can
still finish school and at the same time start this wonderful trip to fulfill
your dream. Visit them at www.ancientartmidwifery.com
for more details or contact me at email@example.com
- Nathalie Steverlynck
In response to Question of the Week, Issue 3:19:
I cannot agree with Eliza Suely Anderson's advice that the woman aspiring to
a VBAC should not attempt birth at home. Of course, many factors need to be considered
in such a decision but previous cesarean(s) per se, does NOT contraindicate. In
fact, I believe in some areas of the United States staying home is absolutely
the only way to ensure a successful VBAC. Eliza made some excellent suggestions,
however, on preparing physically and emotionally.
Also, doula Kelly Marrow suggested 3rd trimester ultrasound (U/S) to help predict
the weight of the baby. First of all, 3rd trimester U/S is highly inaccurate and
should not be relied upon, and possibly should not even be done for that reason.
Secondly, one cannot look merely at the size of a baby or the supposed size of
a pelvis and make such lofty predictions. That is the medical model and one we
should be fighting against. True CPD is extremely rare, especially when upright
positions are used.
Eliza Suely Anderson wrote: "If the time between the previous pregnancy
and this one is less than three years, a natural delivery can be a problem."
I'd like to see references to support this contention! This sounds like pure and
simple fear mongering. When I pointedly asked Dr Bruce Flamm for the time interval
required from one cesarean and the next vaginal birth he hesitated, smiled and
replied, "Nine months." It certainly is the schedule we adhere to in
our practice though we haven't had any takers who had babies less than one year
apart so far.
Eliza also said, "Go to the hospital; don't try a homebirth." What is this counsel based on?
I'm a sectioned mother of two daughters who were born in hospital after two homebirth attempts strongly disturbed by midwives. I must react to Eliza's advice:
Avoid hospital: Do your best to achieve your homebirth plan.
Wait three years for the next pregnancy: Why? The female body is built to bear children. What is the link between pregnancy spacing and VBAC?
Prepare for this birth, including seeking outside help: Trust yourself instead of professionals. Techniques are nothing more than techniques.
Truly understand all phases of the birthing process and what you can do to succeed in each phase: Forget everything you've read before. Find your own way in this birth. The birth process is not divided into different phases; it is whole.
Your client needs you to be especially reassuring, nourishing and supportive:
The woman must be seen as an adult who is responsible for her own birth. She probably needs to be empowered more than mothered. There are risks in putting yourself in the hands of others, but there are no obstacles to doing it yourself with your loved ones.
Don't rush to the hospital as soon as labor begins: If you can stand to stay at home until 8 cm, you CAN birth at home.
- Marypascal Beauregard
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