​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. 

​As doulas our profession is one that is infused with passion. We are passionate about the families that we serve and the beliefs that we hold, but unfortunately a doula’s passion does not always translate into professional communication. There seems to be a never ending obstacle course for doulas in their struggle to conduct themselves in such a manner that honors the profession that they have chosen. Unprofessional conduct from doulas spans from scope of practice violations to lack of respect towards fellow doulas and other providers such as nurses, midwives, and obstetricians. How many times have you read a doula’s post criticizing a nurse or provider’s actions at a birth she recently attended? Have you met a doula who is quick to speak negatively about another doula behind her back or criticize a doula for doing things differently? Doulas then wonder, “Why isn’t the nurse more accepting of me?” or “Why doesn’t that doula refer clients to me?”
 
Unprofessional conduct is not only an obstacle to a doula’s personal practice, but it breaks down the level of professionalism within the doula community as a whole. Professional conduct is actually an easy skill to master. At the heart of professionalism lies communication. With the advent of electronic communication, personal communication skills have seen a significant breakdown. If you don’t use it, apparently you lose it. Luckily, by adhering to the following communication 101 principles a doula can maintain a level of professionalism at all times.
 
1. Think before you speak/act/email. Remember the old adage to count to 10 before speaking? Turns out that this isn’t just a line your parents made up but is a timeless truth. Taking a moment before responding, whether in person or by electronic communication, can easily avoid a knee-jerk response that can cause irreparable harm. When it comes to electronic communication, think about whether you would actually say what you are typing if the person was sitting in front of you.
 
2. Speak with integrity. Choose your words carefully! Avoid words that intentionally inflame or create gossip. Ask yourself, “Is this how I would like to be spoken of/about?” Keep private subjects private, and avoid flaming or gossiping about other professionals in public forums.
 
3. Keep your promises. If you say you can back someone up, help with an event, etc., then do it. If you aren’t sure, don’t commit. Be clear when you communicate expectations around working with other professionals so that miscommunication doesn’t cause you to go back on your word. Don’t leave other professionals or clients in the lurch.
 
4. Don’t Assume. I am sure you know the expression about assuming! If you are ever unsure, clarify with the person directly, and by directly I mean in person as long as it is conceivably possible. While electronic communication can be an effective tool for a quick message, tone and body language are totally lost and these are integral to meaningful conversations. To not take the time to sit down and talk in person might send a negative message about your level of professionalism and respect for clients or colleagues, no matter what profession you are in.
 
5. Treat others the way you would like them to treat you. Is the provider at your client’s birth less than pleasant? Is a particular doula not giving you a warm fuzzy? You have no idea what that person has gone through that particular day. Maybe that person is struggling. Perhaps their loved one is critically ill. Perhaps they have been up for 24 hours working non-stop. Rather than taking it personally and speaking ill of that person behind their back, try extending that individual some grace and empathy. Ask yourself, “How would I like to be treated?”
 
By following these communication 101 skills, you can not only improve your own personal practice, but you can also help to further the level of doula professionalism as a whole. Be an advocate for all doulas by starting with your own professional conduct!

I hate to be Debbie Downer, that is not in my heart at all. I hired a doula for what I thought were realistic reasons. Like so many others, I read the statistics:  shorter labors, lower uses of epidurals, happier feelings after the birth; those were the ones that stuck in my mind. I just didn't expect things to go the way they did, and when they went, they went fast. I felt like my doula went along with that, while I was left behind feeling alone.

I know one admirable quality of any doula worth her salt is good working relationships with the nurses and doctors at the place of birth. I was impressed by the stories I heard from my doula, the goings out to lunch with nurses, the sittings next to doctors at conferences. I will admit, it made me feel like she integrated well into the hospital process. What I didn't expect was that she might need to maintain that balance. When push came to shove in my situation, I did not feel she was with me, on my side. I felt like she was on their side, and it was her job to get me to feel good about coming to their decisions and preferences. 

In a way, this was the beginning of the isolation. I had heard hospital doulas who are provided by the hospital or volunteer/work for the hospital sometimes have a hard time being neutral. I did not worry about this, because my doula was independent and nonaffiliated with the hospital. She did have a family member who was high ranking on the infrastructure of the hospital board, but again I saw this as a bonus, not a deficit. In reality, I think it aligned her with the hospital's way of doing things. It made it seem like her job was to help me buckle to that agenda in a less threatening way than if it came from a staff member.

I had a complication when it came time to push. Suddenly I was being rolled over, yelled at urgently, and told to push, even without a contraction. Extra people came rushing into the room. I was hearing all kinds of instructions at once. I closed my eyes and tried to do what they told me. My husband was no where to be seen or felt. My doula was also lost in the haze. I had no clue what was happening. I needed the tiniest bit of an explanation. The one person I would have expected this from was not there. My doula.

After the baby came out there was an audible sigh of relief. She was taken to a flat table to be given air and make sure she was breathing like she should. I felt the smallest touch from my husband's hand, and I wanted to gobble it up and have it take me away. He was scared too. We watched as our baby was being poked and prodded, mask on her face, lights flashing and alarms beeping. I looked for my doula and she was talking to the nurse about how frightening that was, and how she was sorry the nurse had to get up on the stool to help move me because the nurse was pregnant.

I could have used the emotional support my doula was giving my nurse.

It took a while before anyone explained what happened. It took even longer before our baby was brought to us. I felt pretty insignificant. I felt alone and afraid. Soon after the bustle in my room went down and I was considered recovered, my doula announced she needed to go move her car before her meter ran out. She said she would be right back. 

"That's ok. I think we are ok now." She looked at me with a puzzled expression. "But the baby isn't back from the nursery. Do you want me to wait and see if we can get you nursing?" I let her know I was really tired, and I would ask for help from the staff if we needed it. She came over, gave me a hug, and said, "Thanks for having me as your doula." 

Really I just felt sad. I felt let down. I wanted more mothering, and I got what seemed like a bubble gum teenager who was only with me until the cooler kids came (her friends at the hospital). I am not writing off doulas forever. I still can't deny those statistics. But next time, I am going to ask different questions, and remember to be impressed by different answers. 

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?