​One of the most crucial things we do as doulas is help parents make decisions. It's not as glamorous or often discussed as giving massages, squeezing aching hips, or whispering words of comfort and encouragement (not that any of those things are particularly glamorous). But it's one of the most important things we do.

Decision-making happens frequently during pregnancy. Choosing a care provider, a place to birth, which breast pump to buy through your insurance, what kind of birth preparation class to take, what sorts of things to register for, and so on...the decisions to be made sometimes feel endless.

But during labor, things are different. No longer is there a stretch of weeks or even months before baby is on the way - things are happening right now. Add to the urgency of time the fact that most laboring families are not necessarily calm, cool, and collected the way they might like to be when making decisions. Parents often don't even understand the implications of the options their care team is presenting.

That's where we come in.

In our prenatal visits and birth classes, we often use a tool well-known in the birth world. In fact, it's a tool now used by many who encourage healthcare literacy as a helpful way to approach decision-making with care providers. This tool comes in handy no matter where you're birthing, but we find it's often especially helpful for clients who are having their babies in a hospital setting.

The tool is an acronym: BRAIN. When a question comes up in labor, or a procedure or medication is suggested as the next step, our first suggestion is always to stop and take a breath. Sometimes these situations can be nerve-wracking in labor. So give yourself a moment rather than responding quickly and impulsively.

Once you've gotten a nice breath or two under your belt, take some time to go through the acronym letter by letter and ask some questions. 

B: Benefits The first question to ask is what the benefits of the suggested procedure, medication, or change to the situation would be. Remember to consider benefits both for you and for your baby. We've found that usually care providers answer this question even before you have to ask it, because their suggestion is made with the intention of giving you and/or your baby a certain benefit. But if you have any additional questions about the benefits, ask them!

R: Risks Next to ask is, what are the possible risks to you? To your baby? Usually in a medical setting the answer to this question reads more like the side effects listed on a drug label. While this is good information to know, there are other indirect considerations to think about which sometimes fall outside the realm of the care provider's role in that moment.

For example, sometimes our clients ask their nurse or anesthesiologist about the risks of an epidural. Usually we hear care providers mention things like the possibility of a drop in blood pressure, headaches, nausea, itching, etc. 

However, I've never heard a care provider mention the increased risk of a longer pushing phase, the increased use of medication to augment a labor slowed by epidural (pitocin), or the increased difficulty of breastfeeding after births involving an epidural (probably due to the IV fluids that accompany the administration of an epidural). These are things we discuss with our clients if they're considering an epidural, along with the benefits including "therapeutic rest" if labor has been long and hard. 

If you ask about the risks of your care provider's suggestion and receive information from the drug label, also ask if there are any other indirect risks they know of. (And check in with your doula too, to see if they have any other information that might help you as you make your decision.)

A: Alternatives Ask your care provider if there are any other alternatives that can be tried first before proceeding to the suggested procedure or medication. There may be something less invasive or more temporary that might help address the issue at hand. 

​Often care providers and medical staff are much more comfortable with medications and medical technology in birth than parents are - primarily because they're around those things all the time. They see highly medicalized care help families every day. But most expecting parents aren't in that boat. Our clients are often surprised that their care providers suggested something more invasive when there was a less invasive alternative. Understanding where your care provider is coming from can be really helpful in this case. And of course, if your care provider suggests an alternative or two, make sure to use your BRAIN when exploring those options as well.

I: Intuition What does your gut say about this? How are you feeling about the situation at hand and the proposed next steps? Studies have actually shown that the intuitive, ancient part of our brains (the part that gives us those gut feelings) often works faster than the more analytical part of our brains. Here is a fascinating article on the subject.

It's important not to discount the sensations in your body we refer to as a gut feeling because what it can mean is that some part of you already knows the answer. It may just take a while for the rest of your mind to catch up and figure out the "why." Pregnancy, birth, and parenting involve a LOT of intuition. Don't leave your intuition at the door when you enter the birth room.

N: Nothing Also known as, "What if we wait an hour?" This question can help you determine whether your care provider feels the situation is an emergency or not. If the answer to "Can we wait an hour?" is "Sure, I'll come check in later," you know you have time to think things over. But if the answer is, "Waiting isn't an option - we need to make a decision now," obviously that gives you a different picture.

​If the care provider's response to waiting an hour is positive, sometimes parents are surprised they were being asked to make a decision earlier than necessary. It's important to keep in mind that care providers are often on a schedule and juggling multiple patients at once. Sometimes the timing of things has more to do with their patient load than with your particular situation, which is another reason why it's important for parents to be asking these questions. This question is especially powerful for parents who want to minimize medications and medical technology in their births. 

You should be able to take your time in making your decision unless there is a medical emergency at hand.

After you've had a chance to ask your questions, request a few minutes alone without your care providers in the room to consider your options. (If you have a doula, it could be beneficial to have them in the room with you as you talk things over. But if for any reason you'd be more comfortable having the conversation alone, by all means let your doula know.)

Once you're ready, let your care providers know you've considered your options and made a decision. If you are choosing to accept your care provider's recom-mendation, often the conversation will be fairly straightforward. But if you're choosing instead to try an alternative or wait a while before trying anything else, sometimes care providers can feel that their expertise is being undermined or that someone is convincing you not to accept their recommendation. This is a very human reaction!

To help diffuse any tension if this happens, speak from your HEART when communicating your decision to your support team.

H: Hear "I hear what you're saying and I understand why you recommended this..."

E: Empathize "...and I know you want the best for me and my baby..."

A: Affirm/Assert "...but I intend to wait a while longer before considering x, y, or z." OR "...I would rather try this alternative instead."

R: Reassure "I will let you know if anything changes."

T: Thanks "Thank you so much for your time and for taking good care of us."

These kinds of conversations can be difficult, especially if any medical concerns are present. These tools will give you an anchoring point when making decisions in labor and beyond.

​Remember to use your BRAIN and HEART!

​Megan has been serving growing families since 2014. She is an Advanced Birthing From Within Mentor and doula based in Orange County, CA. She is passionate about providing holistic guidance for her clients, helping them cultivate resilience and openness on their journeys to parenthood. In addition to offering birth doula support, she also teaches birth and parenting preparation classes. Megan practices in partnership with her wife, Marlee, who is also a birth and postpartum doula, childbirth educator, and lactation counselor. Together they serve families of all shapes and sizes with respect and compassion. Find out more about her by visiting Hero Birth Services, or her Facebook page. 

A dear friend of mine invited me into some of the most intimate and profound moments I have ever experienced. I met this wonderful friend years ago when we were both at the beginning of our doula work. She invited me to be present at the birth of her son 2 years ago and then again invited me into her journey of surrogacy.

​I watched as her belly grew, housing twins so gracefully. The journey was unique and had it's challenges, but the gift she offered withstands it all. 

The biological family had experienced the lost of a previous baby after years of fertility struggle. The ache they had to hold their own babies could be felt in their presence. 

We had all hoped and planned for a vaginal twin birth, but one of the twins was showing some concerning signs with growth and nourishment so it was decided it was best to get the babies out at 34 1/2 weeks by Cesarean Birth.
 
The wonderful doctor spoke to the surrogate mother throughout the whole procedure, keeping her informed with each step. He kept each babe connected to their umbilical cords for 1 to 1 1/2 minutes. I thought this was amazing considering that the babies were born so early and had some potential health concerns. 

Fortunately, the babies are both thriving! These two families are now forever intertwined. These images give you an idea of the emotions on this sacred day. ​​

23 years ago, when I started my work as a doula, I experienced some of the greatest highs of my life! After a birth I would sit on the phone for hours, processing this and that with my other new doula friends. I was excited to carry a pager, to know I had a prenatal visit coming up, to be thinking about my doula bag. My learning curve was steep and I was devouring every piece of information I could find. Newly married, my husband delighted in how happy I was. He said, “when I married you I knew I was getting a great woman. I didn't know I was getting a doula as well!”
 
The years have passed. I usually don't need to process a birth for several hours. Usually I come home happy, but not always high. I often feel pressure to get to bed at a good time, be sure my cell phone is charged, know that my childcare is perpetually lined up. The weight of being on call 24/7 sometimes feels heavy. I feel frustrated with marketing my work on social media because really, marketing is not what I love to do. Neither is social media.
 
And yet, the joy of this work continues to fill me. I feel honored to be trusted and invited into what is surely one of the most powerful experiences a woman will ever have. I am humbled as I witness her strength, his kindness, their love. I learn as I watch women make very hard decisions. I help her gather information. I act as a sounding board as she talks through her options. I am present for miracles.
 
Perhaps there is a selfish part of me as all this occurs. I learn so much from these birthing women and from these powerful experiences. When I return from births I try to write down what I learned from the experience. This is part of what keeps me thriving as a doula – it's the learning. While my learning curve about the labor process is not as steep as it once was, my learning curve about life still is. These women are my teachers. 
 
One woman I labored with for a few days never once complained. Trust me – if I had been in her shoes, I would have complained. As we walked the hallways for the millionth time I told her that I was so impressed at how she kept a positive attitude. She told me her story of growing up watching her brother who was very ill. At some point she realized she could complain about their lifestyle, in which regular trips to the hospital were a part of her life, but when she considered what her brother was going through, she felt that to complain would be an unnecessary indulgence. She had developed a mantra in her life: I will not indulge in complaint. Listening to this I began to realize that, in fact, I sometimes did indulge in complaint. The hours we spent together taught me a valuable lesson about myself. I still complain, but maybe just a little less. And my life is better for it.

​Then there was the mother who had everything stacked against her, but she just kept making these great calls for herself as she labored toward having a much desired VBAC. After two sleepless nights of non-progressing contractions, her doctor told her that even though her labor was very mild and she wanted to go home, she couldn't advise her to do so because there had been a few dips of her baby's heart rate in the last several hours. The mother listened to what the doctor had to say, asked a few questions, and then made a decision to leave despite her doctor's advice. This was not someone I thought would ever even consider signing out AMA (Against Medical Advice), but she said she dug down deep and just knew it would be worse to stay. She had never heard of signing out AMA but described doing so in her own words to the doctor. The doctor said she completely understood what the mother was asking for and that she only was telling her the hospital's policy. As I followed the mom out of the hospital, her nurse whispered into my ear that she would have made the same decision for herself. The laboring mom left the hospital, got some much needed rest, but went on to encounter many other obstacles. Despite them, she and her baby had a very healthy VBAC. The lesson to watch for miracles was reinforced for me at this birth.
 
I have learned that slow and steady progress often makes big changes. Not just in dilation! But even in birth advocacy.  I have encouraged and watched as women kept asking for their babies to be taken out of the warmer and placed in their arms. Now it's standard for babies to be placed in mom's arms after birth.  I have suggested to women that they might consider delaying their baby's first bath. Now I attend births in hospitals that post that they prefer not to wash babies for 24 hours. Episiotomies were routine. Moms complained. I haven't seen one in 6 years. I've learned that health care consumers really can make change if they are supported.
 
When I think about why I keep doing this work, it is because it fills me up. It makes me smile. This work helps me to learn and grow. The highs are not always as high as they once were – but the lessons are so much richer. Where else could I receive these powerful life lessons than at a birth?!

​“Why are you still working?! Your due date is next week, what if your water breaks while you’re at work?”

“Oh that’s not going to happen to me, they do that in movies for dramatic effect. In real life, the water breaking in a gush only happens to about 8% of women, that won’t happen to me, I will be fine”

This was a conversation between myself and my good friend Jammie one week before my October 13th due date with my first child. I had an easy pregnancy, no morning sickness or vomiting, and I had not taken a single day of work off the entire nine months. I manage an office, it’s not physical work and since I had felt fine, I felt no reason to stop working even with my due date right around the corner. I wanted to maximize my time off after the baby arrived. Little did I know, I was about to be one of those 8%...

On the morning of October 14th, one day overdue, I awoke to my dog barking. She doesn’t usually bark at night unless she needs to be let out to answer the call of nature. I groaned internally. “Ugh, it’s 2:30 a.m., I don’t want to get up and let her out,” I complained internally. Then I thought, well I probably have to pee anyway, it’s only been an hour since last time I peed and everyone knows how often pregnant ladies need to pee. I heaved my big, pregnant belly up and began walking to the bathroom. "Oh, I guess I really had to go," I thought, as I felt fluid trickle. By the time I got to the bathroom, there was a gush and a lot of fluid. Apparently my water had broken, signaling that the arrival of my baby was imminent. I called to my husband and told him to get up and let the dogs out while I cleaned up.

The first call I made was to our doula. I had made the decision to hire a doula fairly early in my pregnancy, and she came highly recommended from a mother of 6 that I have known my whole life. I hired a doula because I was afraid of having a hospital birth, I was afraid of being forced into taking unnecessary medical interventions during labor, and afraid of being bowled over by a medical team that had never met me, knew nothing about me or my baby, and didn’t know what I wanted from my birthing experience. I envisioned an intervention-free birth, preferably at home, with a midwife. My husband, rightly concerned with my health and that of our unborn baby, objected to my home birth plan and preferred a hospital setting. The compromise came in the form of our doula, who I wanted to help me through an intervention-free hospital birth.

“My water just broke, should I go to the hospital?”

“How do you feel? Have your contractions started yet?”

“I feel fine, I am not in pain and having no contractions yet.”

“It’s up to you whether or not you’re ready to go to the hospital. However, it can take some time for the contractions to catch up once the water breaks. Since your water is broken, if you do go to the hospital, it's likely they won’t allow you to leave once you’re there.”

“Ok, well I don’t want to go too early, I think I will wait a while and go later. I should not go to work though, right?”

“NO!!! Do not go to work, and keep me updated.”

After getting off of the phone, I called my mother and told her the news. I told her I wasn’t going to the hospital yet and I didn’t expect the baby to arrive for several hours, probably not until late evening. I expected a long labor, everything I had heard and read said that most first time mommies have a long labor so I was prepared for a marathon. With this in mind, I decided to go to work. This decision was made because I knew I couldn’t get someone to cover me, I work at 4:30 am, and I just planned to go briefly to give a quick morning meeting and inform my staff that I would be out until the end of my maternity leave. My husband got dressed and drove me to work, and I was there for half an hour before we left and drove through McDonald’s for breakfast to be fueled up for all the work ahead of me!

At home around 6:30 am we both laid down, I wanted us both to try to get some rest for the long day ahead. I was having minor contractions at this point, 15-30 seconds long and 5 or so minutes apart. At about 9 am I sent my husband to drop our dogs off at a friend’s house. My contractions had increased in frequency and length but I was still not ready to go to the hospital. I was texting our doula and asked how long I could safely wait to go to the hospital? She said it was up to me how long I felt safe staying home, and she advised me to contact my doctor for an appointment to check my progress. If I had progressed enough, I could go directly to the hospital, but if I wanted to go back home, I could do that too. That sounded ideal to me, my doctor’s office was located in the parking lot of the hospital I would deliver at.

This is why I wanted a doula and why I decided to go with our doula specifically; she listened to me, asked me how I felt, and asked what decision I thought was best for me. Essentially, she helped me to decide for myself instead of just telling me what to do or what she thought was best. From our prenatal courses, she knew my concerns about having a hospital birth and advised me with that in mind. Our doula knew that I was concerned about going to the hospital too early in labor, and that I was concerned about having my movement in labor restricted by monitors and hospital rules.

The most important thing that I learned from our doula was that I had choices for this process. I could be in charge. There were productive ways to communicate with hospital staff to facilitate the birth that I wanted, and decisions that I could make to affect my birth, like the decision to stay home and labor for a while instead of going straight to the hospital when my water broke. I didn’t have to be merely a participant in my labor, I had choices and a voice. In our prenatal courses, we had talked extensively about my birth plan, making 2 or 3 drafts before we were satisfied with it. I also made a gift basket for the nurses and doctors in the hospital, to thank them for their hard work, and partly to schmooze just a little bit! The birth plan would help to communicate what I wanted in the heat of labor, and the gift basket would help them to remember me in a positive light.

​I called my doctor’s office. When I told them my water was broken, they told me to go straight to the hospital. I explained that I wasn’t ready yet and that I wanted my doctor to check me first. Fortunately my doctor was working and agreed to see me at 11:15 am. I took a shower, which was the best shower I have ever taken in my life, so relaxing! And my husband and I departed for the doctor. We pulled into the parking lot shortly after 11 am and I knew in my heart that we weren’t going home. My pain level had increased significantly since 9 am, but I was still unsure whether or not to go straight to the hospital. In my mind, I was clinging to the 4-1-1 rule (contractions every 4 minutes, 1 minute in length, happening for at least 1 hour) and I wasn’t there yet! My contractions were only about 30-45 seconds long, and I didn’t think they were long enough for me to go to the hospital.

Once in the doctor’s office, I had trouble disrobing from the waist down and getting up onto the exam table. When my doctor arrived and checked me, we were both surprised to find that I had already dilated to 5! It was time! I was going to the hospital! I was put in a wheelchair to go across the parking lot. I texted our doula: “I am at 0 station and 5 centimeters dilated, I need you here ASAP!” “I’ll be there as soon as I can!” My husband accompanied me to the room and I sent him back out to the car for the hospital bag. The desk nurse gave me a hospital gown and asked for a urine sample. I got into the gown but the urine sample wasn’t going to happen. I was in too much pain, and I curled up on the hospital bed in the fetal position instead.

When my husband got back from the car, I was crying. “I need an epidural, I can’t do this, I’m going to die!” Cue the theatrics! He went for help. The nurse checked me and immediately ordered a birth kit; baby was coming faster than any of us anticipated. I asked for an epidural. My husband asked if I was sure, and in that moment, I certainly was! The nurses told me it would be at least an hour before I could get one; in retrospect I am sure they knew there simply wasn’t going to be time. The baby was going to be there before the anesthesiologist anyway! Our doula arrived around noon I believe, and everything became a blur. I was very lucky that my doctor was on duty and was there for the birth. Between her, our doula, my husband, and the nurses, everything seemed to happen at lightning pace. Almost immediately, they had me pushing, I had plenty of help and support. My dear husband, who had pledged to stay by my head during labor to avoid the potentially traumatizing show, found himself holding one of my legs up while I pushed, after a nurse said “here, help her." Before I knew it, baby was crowning. My doctor asked if I wanted to touch the head? “No! What are you talking about?! We are wasting time, let’s get her out of there!”

At 1:13 pm, Tegan Janine arrived. 7 pounds, 3 ounces and 18.5 inches of pure, healthy perfection. I remember seeing her for the first time, her arms outstretched. As they laid her on my chest, I was overwhelmed with emotion and disbelief. She had arrived so quickly, I was caught off guard and burst into tears, “I’m just so happy." Delivering the placenta was slightly problematic, it didn’t want to dislodge itself. The doctor massaged away at my abdomen for 20-30 minutes, and I cursed loudly…but it was eventually delivered. I was given a shot of Pitocin in my thigh because I was bleeding a little more than they would have liked, but otherwise everything was fine.
​ 
All of the preparation and planning were worth it. The decision to hire a doula and educate myself on my choices and decisions was crucial. I am extremely fortunate that I had an easy pregnancy and a fast labor, many mothers aren’t as lucky as I was. I recognize that genetics and pure good luck played a huge part in me having a positive labor experience. I hope that by sharing a positive story of birth, other mothers can feel more confident. There are so many terrifying stories of labors gone wrong, I feel that women need to hear that labor can be a positive experience.

​When living in Chico, California, and starting as a doula, I did not enter this work with a professionally-created business plan clutched in-hand – I walked in with my heart open and extended, ready to help families. The focus on business in the doula world has been huge in the last few years, and I absolutely see the value in that. When I started as a doula, there simply were not resources past the doula trainings we took. I did as many others did – made things up as I went along. With freedom and (eventually) experience, I made changes as needed to better fit how I wanted to do business. I have known all along that I do things differently than many other doulas, and I am perfectly content in that. In order for me to stay sane, happy, and sustainable as a doula, my business beliefs and practices have to match me. Take, for example, payment.
 
It is the norm for doulas to be paid-in-full before a baby is born – often by 36 weeks. The agreement generally is, if you have not paid your doula before your birth, she does not consider herself on call for you. I deviated from this years ago after seeing an uncomfortable situation with a doula friend and her client.
 
Anne was called to labor with a client at home. The client had not yet paid the second half of Anne’s fee, but Anne made the choice to attend her client. After a night spent working through contractions, labor stopped. Anne left to wait for her client to share when labor began again. But Anne’s client never called, and soon Anne learned the baby had been born. Expecting to be paid, Anne contacted her client to make arrangements. The client, though, expected that since she didn’t have direct doula support for the birth, nothing was owed. For weeks and months I saw this play out, and I felt bad for Anne. The amount of time and energy she put into trying to collect payment was painful to watch. I understood Anne’s side of things, and yet I could imagine a situation where her client felt good about birthing without a doula.

Anne never was paid.
 
I have since moved from Chico to serve the areas of Visalia and Bakersfield, yet my belief hasn’t changed: my true heart of this birth business lies in wanting families to have what is right for them – even if that means they change their minds about me. I cannot stress this enough! Thoughts come to me: what if a family finds that fee-remainder would be more important to them than doula support? What if I miss a birth? What if they are laboring confidently and a doula’s presence doesn’t fit the flow of their birth? What if a planned cesarean birth is needed and they feel well-enough supported? I wanted my clients to have an “out,” to be free not to call me, without worry of penalty.
 
My contract expectations are as follows:

• non-refundable deposit due at contract-signing (half of total fee)
• remainder due at postpartum visit (other half of total fee; yes, due after the birth)
• if I am not at the birth (they fail to call me, precipitous labor, illness, etc.), no additional money is due, we are square with the deposit to cover our prenatal time together
• if after a missed birth they wish me to come to the hospital (precipitous situation), the fee remainder goes down by 1/2; again, due at our postpartum visit

 
There it is – all in place should a family find it useful.
 
This structure is worrisome to many doulas I have shared it with. What about being on-call and then suddenly having your time wasted by not attending the birth? Unless I block my calendar out for specific dates (and as my husband is a teacher, I block out some time in the summer), I am on-call a lot. When weighing this as an option for families (against my inconvenience), I want families to win.

Ultimately this has been more of a non-issue: I am getting close to 200 births as a solo doula, and I changed my contract to reflect this option around birth 30; in all of that time, I have never had a family NOT call me, and I have never had a family NOT pay me. So why keep it in my contract at all, if it isn’t going to be used? Because I believe birth is a time when your choices shape your outcome – and who is on your birth team should always be one of your choices. 

Recently for the Bakersfield BirthNetwork, I was presenting on comfort measures for birth. Expectant families, as well as doulas, come to these gatherings, and I love being able to offer information that is not only helpful to parents, but also information other professionals can take to their clients! As a Lamaze-certified Childbirth Educator, I am always putting together ideas in an unusual way to help make learning about birth fun!

The inspiration for this started when I had a few ideas I wanted to squish together into an activity:
1. Update the stages of labor to reflect an additional pre-labor phase at the onset of the first stage
2. Scaffold the stages/phases of labor by choosing and practicing supports meant to intertwine with the key emotional and physical events occurring
3. Provide a handout which not only helps visualize the opening of first stage, but also serves as a cheat sheet to labor happenings, timing, and ways to cope

What I came up with, I call the "Spinning Circles of Womb." Just kidding, I don't. But I think it works, and it's pretty simple, and that's all that counts -- no frilly title needed. Basically, here are the supplies: 

• items/ideas that comfort
• items that encourage art
• non-negotiable for this activity are 4 circles measuring 3cm, 6cm, 8cm, and 10cm, tacked together with a metal fastener 

I can't remember a time when I sat participants at a table, but for this activity we did, indeed, sit at a table. Surrounded by Mr. Sketch Markers, paper circles, and stickers, I began to share the stages of labor by tacking three sheets of (laminated) paper onto the wall. There is relief when an expectant parent realizes there are only three stages of labor (I did have a dad once who suggested there were 14, but that was his lucky number, and I asked him to take a guess!).

Three. That's not hard to remember, right?

​Then I tack up two more papers, which you can see below, right. I share how some genius decided to break the first stage of labor up into phases, which is another word for, let's just insert more stages into this stage and call it good. 

On the front of the circles we write things like average length of that phase, approximate cervical dilation achieved, contraction action, and more (note: I don't show all of that in the picture). The pinnacle of this is affixing the face sticker to the appropriate phase​, as a handy visual reminder of what a laboring person might be feeling in that moment. 

While we are moving through the phases with markers and stickers, we are also brainstorming what comfort measures might be beneficial at what time, and those are added to the back of that circle. We practice these comfort measures as we go. If we expect people to feel comfortable with different physical ways to counter the strong sensations of labor, we can't expect them to get there from a picture alone! Would you step into a ballroom, ready to dance in front of judges, simply from pictures you saw in a book? We need to actually show families what these positions and movements look like, how they feel, and when they help -- or they are of no help at all.

​At the close of this activity, families walk away with their concentric circles of information, a piece of pool noodle, and an information sheet which shows about 20 different physical positions of a laboring person and partner working together.

Not a bad way to merge my three goals! A handy takeaway that can be utilized easily during birth.

I'm a doula. I love what I do, and I am really good at it. It is always an honor to help a family through birth by offering physical, informational, and emotional support unique to their situation. And I also recognize, as a certified Lamaze educator teaching families in the Bakersfield and Visalia areas, there are many reasons why a family might choose NOT to employ the services of a doula. These reasons might range from cost, to comfort, to hospital rules. In this situation, I want pregnant people to know how to shape their partner or other birth supporters into a doula. 

What are the advantages of a doula? How is she different than a partner, BFF, mom, etc.? She has no agenda or investment in this birth experience except to help a laboring person feel supported and know their options. 

What are the advantages of the partner, BFF, mom, etc.? You know this person better than anyone in the room. You know the likes and dislikes, the history and beliefs of this person, and you will be around after the baby is born.

I often open this topic by asking each person to tell me something he or she knows about the person they have come with. I like this activity because it shows there will be professionals surrounding this birthing family, and while the professionals will know all the medical "stuff," the partners will know the pregnant person better than anyone in the hospital. Labor support is not rocket science. When you know what a pregnant person likes and dislikes, when you know what care this person would appreciate when sick or stressed, when you know what relaxes and what tenses -- this puts you in a prime position as a supporter, and suddenly you have something just as important as the professionals around you. By sharing things they know about each other ("She loves rocky road ice cream," "He hates his head touched") they see already they are armed and ready to doula their loved one. 

​I make goodie bags for all the families. They are filled with objects that symbolize a trait, activity, or way to support someone in labor. 

• Ladybug Straw: stay hydrated; bugs remind us of germs and the need to wash our hands, put a towel on the birth ball, put shoes on when walking, etc.
• Tissue with Yoda on one side, R2D2 and C-3PO on the other: Yoda's "Do or do not, there is no try," for encouraging words, peace through The Force, learning from the master (who's the master???); the droids represent friendship/partnership, C-3PO interprets what R2D2 says like a partner can interpret what a laboring person needs
• Plastic Frog: all fours position for labor or pushing, staying active and changing positions,  change/metamorphism (if it's not working, change it up)
• Sucker: be sweet as you offer support, it's wrapped up like a baby in a pregnant belly, it can provide pressure to a receptor spot on the roof of the mouth which released endorphins, and a reminder to eat while in labor
• Ring Squirter: use of hydrotherapy -- shower, tub, ice
• Gold Medal: treat laboring person as a champion with lots of verbal reminders, and be a cheerleader
• Gum: it smells good (reminder to use comfort scents), partner is not allowed to have bad breath, it "sticks together" like partner and pregnant person
• Watch: of course we time contractions to help us know where in labor we might be, reminder to "watch" the pregnant person and not the machines or the clock
• Head Band: this can bring comfort for unruly hair, it can also remind us this is an athletic event
• Whistle: blow stress away, there may be loud noises, and as a support person, "don't blow it!" 
• The Princess bags: If there ever was a day a person should be treated like royalty, it's the day you birth your baby!

When you love doulas, believe in their benefits, and are a professional doula yourself, it can be hard for class participants to feel you are unbiased on the subject (even if you are a professional childbirth educator, as well). I feel by offering an activity like this, you can show there are many different ways to create a birth support team -- and with anticipatory expectations of what a laboring person's needs are -- that doesn't have to include a doula.

I cannot say how much I enjoyed Bryna's contribution. Isn't there enough of a language gap in the birth world? Dilation when we could say open, and effacement for thinning? What about other terms, such as advanced maternal age (which perhaps is a step up from geriatric pregnancy!)? Or fragile pregnancy? Often these terms serve to make the distinction between doctor and patient. What about words that make the distinction between doula and parent? I hope this gets us thinking!

I’ve worked in the birth world for 10 years, this year. At first, I had what I thought was “burnout” or getting tired of being so emotionally and physically available for clients -- which causes a sort of cynicism and laissez-faire attitude toward one’s responsibilities. I went to work for a couple of weeks thinking this -- visiting clients and being as helpful and present as ever, I realized how happy this work continues to make me, and how capable I feel -- without cynicism. So, if I’m not burnt out, what am I?

I can’t figure it out -- and I’m still sorting through my feelings on this, but let me lay out for you what I’ve discovered so far:

Our language as birth workers, as a general whole, sucks. I’m sick of it. I am so tired of “trust the process” and “it’s not stronger than you, it IS you,” and a thousand other cliches we fall back on as birth workers. As doulas, lactation consultants, midwives, and other affiliates in this world...if I hear about one more person “re-centering” I might scream!

Is there a place for self-care and energy work? Sure. Is it imperative we learn the language and speak circles around our clients? No. No. No. When you tell a client that their “energetic blockages might hold back their labor” you are not giving them information. You are disempowering them, at best, alienating them at worst.

Maybe your particular client needs to move past a fear, a worry, or whatever the heck before they can go forward -- we have all seen this happen. Once, I had a parent hang out at 6cm for HOURS until we FaceTimed their blissfully sleeping kid at Gramma’s house. Baby came within the hour. Was it their “energetic blockage?” Maybe. Or maybe they just needed to know their kid was ok. Or maybe those are the same thing -- but which one uses the flowery language?

Why do we feel called (even saying “feel called” makes me twitchy) to use this flowery prosaic speech when we discuss birth? Some of us use it our whole lives! What difference does it make? What harm could it possibly cause?

I’m working on that part.

I suspect it does make a difference and it can cause harm. I’ve made an active shift away from the “birthspeak” this past year or so. Working to actively remove the embroidery from my words, I am seeing more and more that it’s elitist, exclusive, and I think, harming our communities.

Even if you say “let’s do some yoga breaths” and go on to explain the concept and action in an easy-to-grasp way, you’re reminding your client (who needed to ask you for an explanation) of somewhere they don’t have access -- whether by financial or social exclusion. You have also brought forward a lack of knowledge in a way that isn’t necessary. This can cause more feelings of exclusion. Perceived or real, exclusion is exclusion. You have already lost a little bit of common ground with your client. This is harmful. I won’t go into microaggressions here, because they’re much better explained here and you can see the impact on those who have experienced them here.  These things can add up, and diminish your client’s self-efficacy, or pride and feelings of capability.

Perhaps the internal dialogue of your client then goes like this: “How can I be a good parent if I don’t even know what a yoga breath is?! Once she explained it, it was so simple -- just breathing in my nose and out my mouth! There’s too much to learn, I’m too overwhelmed…” 
 
Was this your intention? Of course not! Is it sometimes the unintended consequence of BS? You betcha. That sentence above is taken directly from the experience of a former client of mine, describing their experience with one of their childbirth educators. BS can impact us all.

Something else to consider as potentially harmful -- a lot of the language is appropriated from other cultures without thought or permission. Co-opting other cultures’ sacred rites & rituals because it feels “more spiritual” is not okay -- especially if you don’t know the significance of the words you are using. Think about it. Think about the things that you do every day as a birth worker -- do you really need that “Namaste” email signature?

My journey to becoming a doula makes plenty of sense in retrospect, but it is a winding journey. I entered college as a pre-veterinary science major, ultimately switched to a Psychology major, hated counseling but fell in love with animal behavior research, and graduated with a BA in Psychology, Biology minor, and Biology Honors. I then entered a PhD program at the University of Nebraska-Lincoln in the Biological Sciences with the intention of becoming a research professor. I actually completed my coursework for a PhD, but cut my research short to graduate with a Masters when I decided a career in academia was no longer what I wanted. After graduation, I became a homemaker and mom when our son was born 5 months later. When he was 10 months old I completed my doula training with DONA International, and attended my first doula birth one month later. Now my husband and I have three children, I am a certified birth doula with DONA International, a Hypnobabies Childbirth Hypno-Doula, co-leader of ICAN of Lincoln (International Cesarean Awareness Network), and have attended more than 55 births. I have a passion for teaching others, empowering women and families to love one another better, birth, birds, and chocolate.
 
I wanted to write a guide to other doulas and to parents-to-be on how to find, read, understand, and use primary research literature. When you have found, read, and understood the research, using the information will be a highly individual decision that only the patient themselves is able to make, based on their intuition, desires, trusted counsel, and circumstances. Yesterday, I discussed how to find and read research papers in Part 1. Here in Part 2, I walk you through a short research article and talk about how to understand the paper, and how to use that information.
 
Here is a short example of how I read a research paper. This article is a short write-up of a conference poster session. This is preliminary research, it is probably not peer-reviewed (critiqued by other scientists in the field to make sure it is done well), and though we can still gain valuable information from it, keep in mind our knowledge can change drastically with more studies, more research, and better analysis. Go read it. Really. It's quick, you'll be back in no time! Here is the paper (if you want to and have the means, print it out and grab a pen!):
 
Afshar, Y; Wang, E; Mei, J; Pisarska, M; and Gregory, K. 279: Higher odds of vaginal deliveries in women who have attended childbirth education class or have a birth plan. American Journal of Obstetrics & Gynecology, 2016;214(1):S162.
 
Since this is such a small write-up, there is no introduction or background section, simply a research objective. Do Child Birth Education classes (CBE) and/or birth plans impact the delivery mode of those women?
 
Let's look at the study design. The authors looked in the past (retrospective) at a group of women all from the same period of time with similar demographic characteristics (cohort study), and give the dates and type of birthing facility. Because birth modes can differ so much between singles and multiples, the authors only looked at singleton births. They also divided the groups into all moms, and just moms having their first birth (nulliparous). Then they divided each group into moms who attended CBE, those who had a birth plan, and those who did both.
 
Understanding statistical analysis is a whole other ball of wax, and there is no way I can explain everything here. What you need to know is when p-values are reported (p=0.01, p>0.1, p<0.0001, etc), the smaller the p-value, the greater the effect of the variable being tested. The p-value is basically the probability that any difference between the groups is due to chance, so if the p-value is small, the difference between the groups is probably due to the different variables. There is a lot more to statistics than just understanding p-values, but there's your crash course in statistics for today.
 
In this study, there were over 14,000 births that were included in the analysis (met inclusion criteria). There were differences between groups of women who did and did not attend CBE and/or have a birth plan. After adjusting for these population differences, the authors found that women who had attended CBE, had a birth plan, or both, had higher odds of a vaginal delivery compared to the group who did none of those, but there was no stronger effect of doing both. This effect was true of first-time moms as well, so the impact of CBE and/or birth plans is the same no matter which birth this is for a woman. In their original poster session, the authors likely included more figures, including their logistic regression analyses, which would help us understand the relationship between the variables and their effects, but it's a simple study and we can understand the basics with the information given here.
 
The authors conclude that attending CBE and/or having a birth plan increase the odds of a vaginal delivery, and they state that further research is needed to understand how this works. In my opinion, given my cursory understanding of this study, I think this conclusion is sound.
 
The questions I have after reading this are:

• Does the type of CBE class and/or birth plan matter?
• It seems like the number of women who had both attended CBE and used a birth plan and those who only wrote a birth plan were very close. Did most of those women who wrote a birth plan also attend a CBE, or is this an incorrect assumption?
• Does the type of class a woman took impact whether or not she writes a birth plan?
• I would have liked to know about how many scheduled and unscheduled (emergency) cesareans were in each group of moms. And the reason for the cesarean?
• How about assisted vaginal delivery (forceps or vacuum) and CBE and/or birth plan?
• I would have liked to see figures of the data, not just the study design, hopefully this research will be published in full soon.

Finally, the authors found a statistically significant difference in delivery mode based on CBE and/or birth plan, and with a relatively small group of women! In human research, 14,000 people is really not much. That's approximately the population of downtown St. Louis, MO. To find a statistically significant effect in a small sample size suggests that either it is due to random chance, or this is a very strong effect. I am excited to see what further research shows in this area!
 
In lengthier research articles, there would be a list of references. For more information on the topic and related topics, this list is where you want to start. In lengthier research articles, there would be a list of references. For more information on this and related topics, including additional studies, this list is where you want to look.

Now, how do you use this information, either for your doula or CBE clients, or for yourself? First, you must understand that research does not, and can not predict your outcome. Research is not a crystal ball, it cannot predict with certainty, in real life, who will and will not experience which outcome. In addition, the facts, found in the scientific literature, are an important piece of any decision-making process. But your intuition, your desires, the availability of options, the counsel of trusted medical caregivers, and many more variables will come together to determine the best decision for you in your circumstances. Science tries to isolate variables, to pinpoint and quantify the exact effect of one thing, which is vital for understanding how one thing affects another. But we do not live in a laboratory. Applying those results to real-life, complicated, individual healthcare decisions is something that only the patient themselves can do.
 
I hope that now you are better equipped to find, read, understand, and use primary research articles. Happy reading!

In my classes, I have an activity I am pretty sure I learned in my Passion For Birth training where parents are encouraged to draw their ideas for birth. Taking left-brain concepts (hospital stays and medical procedures) and using right-brain-directed activities (drawing and coloring) blends our thinking and enables us to synthesize ideas, versus analyze them. What's the difference? When you analyze something, you have a singular focus on it and it alone.

​Imagine being worried about having an unneeded, unwanted, unwarned-about episiotomy. Analyzing this can lead to worrying it might happen to you, without much recourse or thought into the bigger picture of how to prepare to avoid it. Synthesizing takes many pieces of information and plugs them into a bigger picture. In the case of episiotomy, you can learn when they are medically necessary, ways to prevent them during labor (for example, avoiding getting over-hydrated) and second stage (avoiding purple pushing and being more upright), your doctor's opinion and habits, and your birth location's statistics.

Here are pictures from students in my Chico, CA classes (I currently offer Lamaze childbirth classes in Bakersfield, Visalia, Hanford, Tulare, and many places in between and beyond).