May 16, 2001
Volume 3, Issue 20
Midwifery Today E-News
“Doulas”
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THIS WEEK'S ISSUE

Contents:

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Quote of the Week:

"Mothers' arms are, by far, the safest baby warmer that has ever been invented."

- Doris Haire


The Art of Midwifery

A Doula's Birth Bag

  • A draw sheet, large towel, or baby blanket for tug-o-war during pushing
  • Two sets of tennis balls in two white tube socks for counterpressure for back labor. Roll them up and down mom's back.
  • Rice pack: fill a white cotton tube sock with 3 cups uncooked rice, microwave--use as a heat pack
  • Ziploc bags for ice
  • Oils for massage
  • Battery-operated hand-held fan and extra batteries
  • Two pairs of cotton tube socks in case mom's feet are cold
  • Assortment of wooden massagers and rollers (wash with disinfectant between each birth)
  • Personal care items for yourself such as toothbrush, toothpaste, mouthwash, tampons, pads, clean underwear, washcloth to freshen up, deodorant, change of clothing
  • Ponytail holders
  • Soft music or relaxation tapes
  • Emergency kit
  • Sterile gloves, sterile bulb syringe
  • Two books: Mother Massage by Elaine Stillerman and The Nurturing Touch at Birth by Paulina (Polly Perez)
  • Labor ball and cover, plus extra plugs
  • Food for yourself!

- Crystal Sada, The Birthkit, a Midwifery Today publication

E-News welcomes feedback about techniques described in "The Art of Midwifery." What experiences have you had with the same or similar technique? What side effects have you noted? What alternatives do you suggest, and why?

For hundreds more "tricks," check out Midwifery Today's "Tricks of the Trade" Volumes I & II. Get both volumes for just $40!

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News Flashes

Researchers at the University of Kansas Medical Center found that almost half the alcoholic men in their study had been weaned at less than three weeks old, whereas only 19% of their 173 nonalcohol-dependent male subjects had been weaned so early. Even when the researchers factored out other potentially influential pre-and postbirth variables such as parental socioeconomic status, age and health, pregnancy circumstances, and delivery details, they found the association still held up. Considerable prior research has been done on animals into the effects of early weaning on development, learning, behavior, and resistance to stress. Much of this work has indicated that early weaning may directly influence the formation of the brain's reward pathways, which are known to play an important role in addiction.

- wire service reports, April 19, 1999

Doulas

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, in The Birthkit Issue No. 23)

- Arts and crafts
- Nanny
- Bookkeeping at home
- Part-time research assistant
- Catering
- Pet care
- CPR instructor
- Postpartum doula
- County fair worker
- School van or bus driver
- Cook (private for friends, etc.)
- Silk flower designer
- EMT
- Ski patrol
- Farm worker
- Substitute teaching
- Fitness trainer/teacher
- Tailoring
- Healing touch therapist
- Translations
- Homeschool workshops
- Tutor
- Hypnotherapist
- 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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This is a plea for help from a student midwife due to qualify in Feb 2002. I live in England with my partner but would love to gain experience working in the States with a view to permanently relocating. Any advice or info about experience or qualifications required would be terrific! Cheers, Caroline

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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

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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
Fairport, NY

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.

- Detrah


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 work!

- 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 given!

- 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!


Switchboard

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!

International Connections

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: ciasco98@libero.it

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
Bern, Switzerland

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.

- E.H.

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 contractions.

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 spurts.

Ask your pharmacist to *provide you* with the reasons for his advice.

- Marypascal Beauregard
Quebec, Canada

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 healing.

- 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 nathie28@hotmail.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.

- Anon.

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?

- Joni
Guadalajara, Mexico

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
Quebec, Canada


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