For almost two months, I have been faithfully blogging once a week. I had the opportunity to leave my doula world here in Bakersfield and visit Scottsdale with my kids -- so I took it! I had this experience, which I knew fit right in to what parents face as they create their personal plans for birth.

A family member works at WestWorld of Scottsdale. This is a huge venue where they host horse shows, rodeos, expos, and auctions. We had been invited to the Barrett Jackson Auto Auction -- we watch this on TV every year. With four boys from 3-17, this show did not disappoint! 

Our family member showed us the following video, in anticipation of our experience -- she was giddy with excitement as the boys watched with dropped jaws:

After we viewed it a few times, I had some questions for my family member. 

"Did you guys know they were going to do that?"
"Did they ask your permission?"
"If they had asked your permission, would you have allowed it?"

Even though she and her whole office couldn't stop watching this video, the answers to all three questions were, "No."

No, they had no idea this was being planned.
No, permission wasn't asked.
No, it would not have been allowed.

There are some scary scenes in this, right? The car drifts past people, past doors, around Mr. Jackson's Bugatti! Things are loud, dangerous-looking, out of the norm for the venue. But the driver has the experience of drifting, and he knows his car. He has learned how the car works, how best to throw a drift, what his car can and can't do. It is obvious he has had a lot of time behind the wheel.  

This fits into how we can craft our birth plans. 

I recently sat with a couple as they worked to put their birth preferences together. The example they were using was mighty -- like four-pages mighty! Four-pages mighty suggests you list every little thing you might even think of doing or accessing or trying. I suggest a less-is-more approach. Include 6ish of the most important choices you want. Now all the others fall under the umbrella of, we will try them if the time arises and the situation fits, generally without getting specific prior approval, but utilizing something until someone says why we can't. Do you see the parallel now? 

So you want to use a peanut ball? Bring it out when it's time -- but you don't need to take up space on your birth plan stating, "Mother will use the peanut ball we brought to optimize baby's position if Mother becomes tired or needs to stay in bed."

Do you get sick or grouchy or faint when you don't eat frequently enough? Instead of writing, "Mother has snacks available and will eat as she feels necessary in order to maintain energy for labor and birth," just pack your food and snack as you need to.

If your goal is to be active in labor, you need not put, "We wish to labor out of the bed, so we will be walking, using the shower, sitting on the ball we brought, and rocking in a chair to achieve this." You can simply show the bed isn't where you want to stay, and get up and get moving. 

Ideally, talking to your doctor ahead of time to discover what specific choices your situation warrants provides leverage. What if your doctor says no to everything you want to try? Then look for evidence. For example, in November 2015 the American Society of Anesthesiologists stated, based on evidence, that "Most healthy women could benefit from a light meal in labor." If your provider isn't keen on that, ask about this ASA recommendation -- why does it not apply to you? You can do this for many of your choices -- find the evidence and ask why you don't fit the recommendation. What is often termed as "hospital policy" can be broken down into "provider preference"; ensure you are getting accurate information.

Learn your choices. Understand how your body and your baby work together towards birth. Decide how you want to shape your experience by the options you face. And go for it.  If you aren't "allowed" to do something, assess the risks and the reasons, and move forward. Try something else. Keep asking questions. Stay busy and active. This is your machine and you know it best.

​Remember that saying: "It's easier to ask for forgiveness than to ask for permission"?

It absolutely applies here. 

It is okay, stay with me. I know you are saying, what? Why would we talk about Doctors during doula month?!!? Doctors are the reason women need doulas in the first place! I would agree, wholeheartedly, that women need doulas, in part, to help navigate the maternal health care system. But I would also agree that part of the reason that women need doulas is that doctors desperately, desperately need doulas too.

I became a doula nearly 14 years ago in my twenties, and I’m not going to lie, I didn’t last long. I had some births that resulted in healthy babies and the mom was…not disabled at the end of it. Even with a doula, these moms did not receive mother-centered care. For a long time I thought I was just unlucky to get some bad birth situations, but now I know, they were all pretty routine. A male doctor telling me in the middle of a baby crowning that most women urologists would much prefer to have Cesarean births because it preserves the pelvic floor (is this really the time? While this patient is purple pushing her baby out in a lithotomy position that only benefits you?). That time the doctor was in tears because she had agreed to induce at 37 weeks because winter holidays were coming up, and no, to keep it short, it didn’t go flawlessly. I don’t doubt she was crying because she was tired, and maybe a bit raw, and dismayed that the baby needed resuscitation and extended procedures to make the transition to independent breathing.  And yeah, her medical malpractice insurance was about to get tested. I certainly had views on the doctors in these births!

So in my thirties I went to school for a Masters of Public Health with the goal of changing birth outcomes through public health, and if that meant throwing the doctor out with the bathwater, so be it. It was no more than they deserved for being such out of date, out of touch jerks.

But now I’m in medical school in my forties.  I see classrooms nearly half full of 21 year old women being called “Guys” by every lecturer and attending, being erased by every lecturer and attending. I see course curriculum that includes nothing on breastfeeding, and when asked a question about normal breastfeeding, an obstetrician says she knows that answer because she has breastfed for three months! Not because as an OB she has extensive and comprehensive training on breastfeeding (they don’t get any), but because she has beaten the odds as a breastfeeding physician (66% of physician mothers do not meet their breastfeeding goals, most don’t make it to three months).  She is also the one that told the class vaginal delivery was a procedure done by a surgeon.

Physician mothers have nearly a two-times increased relative risk of birth complications, because they are doctors, and if anecdata is anything to go by, can anticipate having every medical intervention in the book --  evidence based or not -- thrown at them (perhaps accounting for that increased risk?).

After birth? For the 30% of women residents that are pregnant, they have minimal leave; it may be paid -- or not; they may get to finish the program on time -- or not. There is no required minimum maternity policy for residencies. Even if leave is allowed, many won’t take the whole of it because pregnant physicians are considered a burden on the residency program by attendings and male residents. Most are expected to return within six weeks, if not sooner. Maternity leave for practicing doctors isn’t much better.  On paper they may have 6 weeks of paid leave, but in reality? Maybe their partners have made it clear that the business will not tolerate that much time away.  Don’t even think about taking time to pump! Their employees and staff have better maternity leave.

So get to the point already, you say, why am I advocating doulaing the doctor? Because if ever there was a group that was high-risk for all the bad outcomes of birth and postpartum, while simultaneously seeming to have all of the protective factors, it is women doctors. They set out to become doctors when they are 18, start medical school at 21, and spend the next 4 years being erased as women and indoctrinated into the medical system's way of maternity care. They often have minimal exposure to safe alternatives to standard medical maternity care because of their training, and even if they want something else, the systemic pressure on them is nearly crushing. They are shift workers as residents, they have no protection under the law for breastfeeding because they are salaried, and sure, they have lots education but also lots of debt and not much income. If they are part of a private practice, they struggle to balance breastfeeding and bonding time with the need to go back to work immediately in order to become a partner and thus-financially secure.

​And yet they do not utilize doulas, because they KNOW about birth, they’ve been TRAINED, their OB is the BEST, the nursing staff will help. The research is pretty clear on this too -- doulas improve birth outcomes, increase breastfeeding rates and reduce postpartum depression. Also, research tells us that doctors are frankly the worst patients in the world, because they are doctors. They literally refuse to ask for help because they shouldn’t need it, they have the training, THEY know what to do.  So a high-risk group that would clearly benefit from doulas isn’t using them, doesn’t realize they need them, and I’d like to see that change.

Great, so I want to see that change. What is the big deal if they don’t use a doula? Most women don’t.  True, although that is changing as doulas become more available and the research on their benefit expands. But the big deal is this: Women physicians have the highest suicide rate of any profession, 250% higher than the rest of the population (men physicians are 100% higher than the population rate), and 400% higher than women in other professions. We are doing something so profoundly wrong in our profession that women who should be healers and leaders and colleagues and parents are killing themselves.

​Suicide has many causes, but here is one I think we haven’t talked about enough: physician mothers are providing care and getting none. Maybe if we nurture our physician mothers through their intense times of change and challenge, support them during their births, help them bond with their babies, meet their breastfeeding goals, maybe we could change that suicide rate. Birth can be transformative, or traumatizing. Doulas can help shift the balance for women, and women physicians need this as much as any other high risk group. Time to doula some doctors and change the world. 

As a self-proclaimed wordsmith, I love language and the deeper-thinking behind our use of common words and phrases. I am deeply affected by words, and Julia's awareness of how language shapes and defines a woman's experience of birth is spot-on. Women can choose the words they  feel when describing their births -- as birth professionals, we have a responsibility to use proper, universal terms which present little-to-no bias.

When I meet as a doula with my clients for the first time, one of the first questions I ask is, “What does your ideal birth look like?” Often, those who hire a doula are looking for a certain type of birth, and clients answer, “I’m going for a natural childbirth,” or “I’m wanting to go all-natural.” The term “natural childbirth” is also thrown around frequently in the doula community.

I’m hoping to never hear it again. Does that surprise you? A doula who doesn’t believe in natural childbirth? What kind of doula doesn’t want her clients to have a Natural Childbirth? Hang with me, let me explain why I never want to hear this term to describe childbirth again.

NATURAL IS NON-DESCRIPT What exactly does “natural” mean? I’ve seen this term describe vaginal birth, un-medicated birth, intervention-free, “naturally induced,” spontaneous (non-induced) or unassisted birth (not being attended by a medical professional).

Society is scared of the Word “Vaginal.” Vaginal. Vaginal. VAGINAL! See, it’s not so hard. It’s not a dirty word, it’s a part of a woman’s body! Let’s call it what it is. When I work with clients during their prenatal meetings, we use the correct words to describe their bodies, intentions, and desires for their birth. Here are some words that can clarify what you really mean:

• Vaginal- Used to describe a birth where the baby is born through the birth canal.
  
  
• Un-medicated- Used to describe a birth where a mother does not receive any pain medication.
  
  
• Medicated- Used to describe a birth where a mother receives pain medication during her labor.
  
  
• Spontaneous- Used to describe a labor that starts on its own, without any intervention.
  
  
• Induced- Used to describe a labor which starts as a result of an intervention of any type.
  
  
• Assisted Birth- Used to describe a vaginal delivery where the baby is born with the help of forceps, vacuum, etc.
  
  
• Cesarean Birth- Used to describe a birth by cesarean section.
  
  

IT OPENS MOTHERS TO JUDGMENT IF THEY DON’T BIRTH A CERTAIN WAY In a culture where natural childbirth is considered the ultimate prize for many birthing women, and considered the only “right” way to birth, let’s change the language. We live in a country where one in three women will experience a cesarean birth. Where do those mothers fit in? Are we saying that they had less of a birth because they birthed from their belly rather than their vagina? I recall sitting in my hospital "Mom and Me' group, watching mother after mother feel guilty for not being able to vaginally birth. Are we telling these mothers that they birthed unnaturally?

One word during childbirth can affect the entire tone for a family. One of the most profound things I learned in my doula training was the power of language. My trainer introduced idea of changing the language of cesareans from “sectioned” or “C-section” to “Cesarean Birth.” At the time, I thought it was a rather unimportant change, but once I started using the term Cesarean Birth, I started to feel the impact of recognizing that birth isn’t a procedure that is done to you, but a life changing event where families are active participants.

I feel as birth professionals that language is extremely important. The term natural childbirth, then, implies that there is unnatural childbirth. If there is unnatural childbirth...what is that?

THE TERM NATURAL CHILDBIRTH SETS A MOTHER UP TO FAIL IN LABOR OR TO JUDGE HER OWN BIRTH Early in my doula career, I had a client who wanted a natural birth. For her, that meant un-medicated. This client started to have soaring blood pressure, and the option of an epidural was mentioned. (Epidurals can have the side-effect of bringing down blood pressure. Fun fact, that’s why you also are given fluids via IV at the same time.)

I sat, and listened to this mother as she labored and mourned the loss of what she really wanted, an un-medicated delivery. We processed how high her blood pressure was, and talked about her goals. Eventually she decided her ultimate goal was to have a vaginal delivery, and that an epidural could potentially improve her health enough to achieve that goal. She bravely accepted the intervention, knowing that it could help her along the path to her baby. That mother was NOT failing at childbirth, she was exceptionally brave, empowered, and informed.

THERE ISN’T A WRONG WAY TO BIRTH Guess what? No matter the way it happens, your baby will be born. You will be a mother. You may have the ideal birth you planned for, you may birth via a different plan that unfolded in labor. That’s okay. It’s also okay to have various emotions about your birth story. It’s okay to be thrilled about it, it’s okay to feel despair or loss from it. A Happy Healthy Baby and Mother is NOT all that matters. It’s okay to have mixed feelings, because your experience also matters.

FIND A VILLAGE TO SUPPORT YOU Mothers often find that a birth professional, a doula, can help you navigate your birth while keeping your hopes in mind. Doulas are an amazingly supportive, loving, and accepting. We listen to your hopes for your ideal birth and support you while you prepare for the big event. We will get to know you and your family. Doulas will not just support natural birth, we support YOU. We will help you form a Plan A, B & C, so no matter what your birth brings, you will be supported! Our goal is for your family to experience an informed and empowered pregnancy, birth, and postpartum time for your upcoming new addition.

The Cascade of Interventions is a typical topic covered in childbirth classes. I don't want to say it's like the Domino Theory of Communism,a logical fallacy known as "slippery slope," but it...it kind of is. As moms, doulas, educators, and birth workers, we often can recall someone's "cascade of interventions" story. The important thing when it comes to teaching is to help students understand that the use of an intervention doesn't mean a woman is fated to the "next" likely step -- with education and awareness, she and her partner can be work to avoid the common pitfalls a specific intervention might bring. Basics:

• I like to use story-telling in many childbirth education activities. Roger C. Shank, a cognitive scientist, said: "Humans are not ideally set up to understand logic; they are ideally set up to understand stories." I feel this is an effective way to help participants relate and remember bits of information, versus throwing factoids at them. 
• I have a set of 12 boxes, that when stacked reach over my head (and I am 5'5"). I bought them at Costco about 7 years ago with this activity in mind.
• I have a 12-step story with each step written on its own slip of paper. The first part of the story is in the smallest box. Step two is in the next size up box, etc. I put these under students' chairs before class.
• Parents offer their boxes as size/story dictates, read their part of the story, then stack their box. In reverse-size order we see how even though the small box was no big deal, as the stack increases, it starts to teeter, and it might even fall. I ask a partner to be in charge of holding the stack up while we finish the activity.
• This story starts with the tiniest box in my nesting collection, and it is a benign "intervention," one we might not even consider when looking for offenders: external fetal monitoring. The story ends with breastfeeding being interrupted -- of course the worst thing we generally think of within the context of normal birth situations is cesarean birth; I felt that was an obvious choice. When it comes to cesarean birth, I feel it can be easy for participants to think, "That won't be me," whereas breastfeeding interference seems an idea we can open our ears to.
  

The story I use:

1. EFM: Jamie arrives at the hospital at 3 cm woth contractions about 5 minutes apart. Jamie's coping method is bouncing/swaying on the ball. Once in her room the nurse wants to get a reading on her baby and requests 30 minutes of EFM to get a 'baseline" on baby.
2. limited mobility; increased pain/anxiety Jamie's limited mobility means she is no longer able to sit on the ball through her contractions. Her contractions become more intense, and this starts the F/T/P cycle.
3. pain medication request (Stadol) Jamie is scared about how she can cope with labor if it is going to get worse. She decides she wants to try an analgesic pain medication, which can be given as a shot.
4. labor stalls Jamie finds although the medication takes away some of the pain, her labor has stalled.
5. pitocin to speed things up; IV Jamie now needs pitocin to get into an active labor pattern. This means she will have an IV as well.
6. epidural request As the pitocin increases the strength of her contractions, she experiences F/T/P cycle again. She requests an epidural.
7. blood pressure drops Jamie's blood pressure drops in response to the epidural.  
8. medication for blood pressure Jamie gets meds to counter low blood pressure.
9. maternal fever Jamie has a fever, which could be from the epidural.
10. OFP affected; baby born via vacuum Since Jamie was not able to be more active, her baby has not had help moving and rotating into an optimal position and needs the vacuum to be born.
11. baby has fever; sent for observation, possible septic work-up Baby has a fever at birth and needs to be taken to the nursery for observation and possible tests. Jamie and her baby are separated for 6 hours.
12. separation/breastfeeding affected Breastfeeding is affected.

The bolded statements are being recorded on a large sheet of paper as we read along. After the activity with the boxes, we go through the list and discuss what can be done to avoid or minimize the effects from a specific intervention. This is also the time I hand out basic info sheets about common interventions. 

I hope I included everything? If you have questions, ask! And please "like" my Facebook page to stay up-to-date on the teaching tips I share.