I recently had the opportunity to be part of a training for a local hospital's BFHI process. I wanted a tactile way for people to feel the differences in palate shapes. Needing the models to be comparable to a newborn's mouth-size, I had the idea of using plastic spoons. 

Amber is no stranger to the 31 Days of Doulas project. She wrote about the advantages of a doula who hasn't had children yet, how doulas help in all kinds of births, and her "labor" as she started nursing school. This year's addition gives us a peek inside Amber's life. Nursing school is not easy! And Amber's confidence was shaky -- until she realized the true value those doula skills held. 

​Doula training has a way of bringing out the best in people. Sure, before I was a doula, I was caring and compassionate, but I was also a wild 20-year-old who wasn’t always focused on others. When I completed doula training at 22 years old, my eyes were opened to the injustices that many women and families face as they meet their baby for the first time. I was made more aware of how much what we say matters, and how important it is to simply listen and respect people. During my training, I also learned physical skills to provide comfort. I didn’t know it at the time, but the knowledge I gained over my two-day doula training would stay with me, even when I wasn’t supporting women and families during the childbearing year. Most notably, my doula skills have all proved extremely useful as I’ve journeyed (yes, sometimes trudged) through my last 2.5 years as a student nurse.
               
Prior to starting nursing school, I absolutely loved being a doula. Being present for one of the most intimate moments in a family’s life was an immense privilege. The qualities that I already had were allowed to shine when I was a doula for a family. Once I started nursing school, I was immensely saddened that the magical relationships that I built with my doula clients would be a thing of the past. It was time to become a nurse, and my touchy-feely relationships would only be distant fond memories.
               
At the end of my first semester in nursing school, I was talking to one of my professors about how much harder nursing school was turning out to be, in relation to my expectation of what it would be like. Her response was one I vividly remember. She told me that you can be a nurse forever, and learn all these fancy technical skills, but that it is extremely hard to learn how to be truly empathetic, be good at listening, and have emotional intelligence towards your patient. She told me that it seemed I already had these skills. It wasn’t until she pointed this out to me that I had really stopped and realized just how much I had translated my doula training into my practice as a student nurse.
               
I hadn’t realized it, but I had been all of my patients’ doulas. The older folks who had dementia who just needed someone to talk to, the veteran who was depressed, the widow who was confused and scared because she didn’t know where she was -- these were now my doula ‘clients’. Except, they were my patients. 

There was something that I brought to my practice that was slightly different than some of my classmates. Now, the other students in my cohort are amazing. We are all very different, and have very different skills. Some of them are fearless, they always jump at the opportunity to insert an IV or catheter. I, on the other hand, was sometimes almost petrified with anxiety just thinking about doing something I didn’t feel confident in. Some of my other classmates were really book-smart, they had memorized complex physiological processes and medications. I sometimes compared myself to these other students, and felt inadequate, that I would never be as good as them. But, once I realized that emotional support was my strong suit, I stopped beating myself up.

When it came to talking to patients who were depressed, needed someone to talk to, had just received bad news, had dementia and missed their loved ones, or were in pain, I felt very comfortable. It seemed that knowing appropriate yet comforting things to say came easily for me, and I didn’t shy away from using physical touch on my patients. With this knowledge in hand, the rest of nursing school has been different for me. Yes, I’ve had some tough days (and nights!) but I know that every single one of my patients felt emotionally supported, respected, and truly cared for. I know that if I were in the hospital, this is how I would want my nurse to be, too.
               
Now that I’m at the end of my nursing school journey, I feel confident that I’ve left a trail of cared-for patients in my wake. The unique set of skills that I will always carry with me as a doula can be translated into any area of life, and I am so happy that I don’t ever have to stop being a doula. I am especially grateful that I also had the opportunity to share some of my doula-ness with my classmates. I think some of the knowledge about providing comfort will stay with my classmates. Some of the doula wisdom I’ve shared with my class, which can be translated to almost any patient are:

​I’m planning to start working as a labor and delivery nurse this summer, so I will truly get to put my doula skills to use on my patients. But, I also know that wherever nursing may take me, no matter a patient's sex, age, or whatever brought them into contact with our medical system, I will always be their doula.  

Amber is a special soul to me. Years ago when I was bringing the first of many DONA-birth doula trainings that my former trainer, Connie Sultana, would offer in Chico, CA, I got a phone call. It was Amber's mom. She asked me questions about doulas, the training, what it would mean for someone like her daughter who had a fascination with helping people and a passion for birth. She passed along that information to Amber, and the rest is history! Amber and I became fast friends although we weren't exactly peers -- me with three kids, and she, college-aged and free! But we had a connection, and we built on that. Slowly we started finding more doulas, bringing Connie back for more trainings, serving families, and creating plans for better ways to serve families. Eventually we helped form Chico Doula Circle. All this time, Amber was set on getting into a nursing program. I moved away, and she got into a program -- and here she is, at the end of that schooling-journey, ready to jump into the world as a nurse! Amber will be an amazing nurse, in any field, although her heart is set on birth. I am so excited for what her future holds! 

There was a woman who named herself after the mountains where she had communed with other women and wrote poetry. In the end she went berserk with agitation, climbed out of her hospital bed in an attempt to lie on the earth again. We covered her in blankets as her community of friends took turns sitting vigil. Her strong body and spirit would not give in to disease without a great fight. Back in bed, she lasted for weeks like that, feeding off the fuel she had accumulated over a lifetime until one day, the flame burned all the way to the core and released her free at last.

​There was a woman quiet and withdrawn, who only nodded yes or no. Yet when a dear one entered and approached, she open her arms to bring them in close. Her adult children had lost a father just two years before and her illness had mostly been a secret, a failed attempt at protecting her loved ones from pain. All we can do is be there to support and minimize suffering. The existential journey is their own. At a time when one can no longer deny death, loved ones gather with tears and smiles for all the healing that can finally begin. In the end, friends and family gathered in the chapel to acknowledge and honor her life. Then came a parade of flowers our way, grandiose bouquets perking up the solarium.  

A volunteer angel drops in every now and again, effortlessly singing A cappella, opening the portal within the spirits of the dying, attempting to free them of blocked emotional meridians and move them forward on their individual path, on the labyrinth of existence.  

​An emaciated woman already a skeleton slowly turned to look at me and offer a weak smile, appearing to wonder about my treatment or judgement of a lifelong multi-drug abuser lying on her death bed before she was even old. She is estranged from all family. I offer reassurance that she will be cared for with kindness and respect. She replied "thank you". I suggest that she has experienced a lot of trauma in her life. She replied "scary". Perhaps at birth, or in the mother's womb, she was already addicted. Maybe now, in a time as vulnerable as birth, she can finally just receive love and care without having to do anything to earn it. She seeks to have her pain and anxiety resolved, just like any other human being. And in a couple days, after a week hiatus in the desert, I will return to this work, wondering if she survives still. As a death doula, I will either care for her with kindness and compassion, or if she is gone, I will care for the others who come next to this house.

There is such emphasis on what to bring to the hospital -- you can find a hundred lists on Pinterest and other places. While we try to anticipate what a laboring person will need, inevitably, something may be forgotten. Here's a handy list of things you may already have access to simply because you are in the hospital.

​Every doula learns her own tricks according to the laboring person's needs, the hospital's set up, and the nurses' suggestions. It's always a good idea to ask before you go searching in drawers and cupboards. But I have found, if you have a need or an idea, the staff is supportive of out-of-the-box ways to comfort someone in labor. What has worked for you?

I was at a birth as a doula in Bakersfield, CA recently where the couple's nurse was wearing a mask. I didn't think anything of it. Soon I realized the parents were worried, because you know, people in masks cannot be trusted (reference, anyone?).

Many hospitals require their employees to get yearly flu shots. Even as a childbirth educator and health worker formerly employed by a hospital-based midwifery clinic in Chico, CA I was meant to get the vaccine -- it was all ready for me in our on-site medical refrigerator. But like many, I chose to decline it.

What does it mean if you decline the flu shot? The Center for Disease Control has this to say about health workers and vaccinations:

"CDC conducts science-based investigations, research, and public health surveillance both nationally and internationally. CDC adopts recommendations that are made by the Advisory Committee for Immunization Practices. These recommendations may be considered by state and other Federal agencies when making or enforcing laws. CDC also has infection control recommendations for health care settings. However, CDC does not issue any requirements or mandates for state agencies, health systems, or health care workers regarding infection control practices, including influenza vaccination or the use of masks. However, some employers require certain immunizations. Hospitals, for example, may require some staff to get the flu vaccine or hepatitis B vaccine or take other precautions such as the use of masks." 

(This link also had some very non-helpful links for further information.) 

Enter the mask!

When I noticed my clients were looking at their nurse's mask with trepidation, I explained many hospitals require employees who decline the flu vaccination to wear a mask during flu season. The mother looked relieved as she shared, "I just thought she was sick and still working." That's a pretty scary thought when you are about to have a baby!

I then engaged the nurse in our conversation, so she could confirm or clarify what I had said to these parents. She let us know she had a bad reaction to the flu shot once, and ever since, she declines it and opts to wear the mask instead. 

I have a good friend, Jessica, who works in a hospital and also chooses, every year, to wear the mask. As a mother who has a vaccine-injured family member, her reason is different: "I always tell people that I feel safer with a mask on my face than a shot in my arm. I feel better protected. The flu is not the only nasty thing that goes around this time of year, and when the CDC only promises 18-30% effectiveness for this year's flu shot, I'm 100% protected with a mask on my face." 

The next time you see someone in the health field sporting a mask, don't worry -- they likely aren't sick! They may have just decided the flu vaccination is not a health risk they are willing to take, and this is their way of still serving you safely.

When I was in college, I worked at a gift and candy shop. It was an easy gig, I got to eat all the homemade chocolates I wanted, and I worked mostly unsupervised and alone. I remember distinctly, an interaction with a customer where I just wasn’t feeling it. I decided I didn’t have any energy to add anything extra to my exchange with her. She brought me her merchandise and attempted to make conversation, and I sat with a sour look on my face, going through the motions of ringing her up. (This is all horrifyingly embarrassing to me now, by the way, but as a teen, I didn’t give it a second thought.) Suddenly the woman said, “It seems like you aren’t in a good mood today.” She said it kindly, without expectation, and it hit me: She noticed I wasn’t being nice!
 
Wherever doulas gather, there is a question often asked: “Can I thank a nurse?” Not meaning, can I say thank you when she brings us a chair or a drink, but, when I notice a nurse going above and beyond for my client, can I send her a thank you note later? Is this appropriate?
 
I have heard doulas answer, absolutely not! She is just doing her job. If she hadn’t been your client’s nurse, she would have been someone else’s. She did it yesterday, she did it today, and she’ll do it tomorrow. She is being paid to work as a nurse. She is just doing her job.

As a doula and a childbirth educator, I take clients in the Bakersfield, Visalia, Hanford, and Tulare areas of Central California. I recently attended a birth where I witnessed a nurse just doing her job. It wasn’t that the nursing care she gave was poor – it was just her flat affect showed she simply had nothing else to give. Just like the teenaged-Stacie in the opening story, this nurse was going through the motions with no smiles, no casual conversation, no empathy for the pain my client was dealing with. She was on autopilot, she could have been a robot, and we all noticed it seemed like she was in a bad mood. In that moment, it felt like she hated her job and resented the fact that someone dare be having a baby on her shift in L&D.
 
As people, don’t we like to hear when someone notices and appreciates the job we are doing? I know I do! Why not, then, send a note to a nurse you felt went above and beyond versus just doing her job? In fact, send it to her boss, and her boss’s boss! Send that praise onward and upward! Let the world know you appreciated this nurse’s attitudes and efforts, her care and concern.
 
Fortunately, I can say this is a rarity. Most of the nurses I encounter are helpful and kind to the families they serve. We all have bad days, and I bet that lady I served so long ago doesn’t even remember me and my attitude way back when. But the day your baby is born – every person who walks in or out of that room can become a permanent fixture in the recollection of that memory. I still have deep, personal feelings for the nurses who cared for me through all my births, and how grateful I am that they are filled with positivity!  ​

​

I was all for a doula, once I realized what doulas do. While pregnant, my wife's idea of a fun night together was sitting at the library, pulling down pregnancy book, after birth book, after breast feeding book, after baby book, and telling me all the things I needed to know. My idea of a fun night together was...not this. Don't get me wrong, when it is time for me to buy a TV or a car or a grill I am all about reading up on all the specs and reviews I can possibly find. When it came to having a baby, I was content to just go along with the flow; I didn't know there was much choice out there or options to decide between. Bottom line: if a doula was an encyclopedia of all-about-babies-and-how-they-get-here, then sign me up...because I need to focus on the best carseat and crib and baby bath.

Our doula came to our house and brought information when we needed it. When my wife had a question and wanted the best information about it, bingo, best sources without having to scour the internet. 

When I was out of town for work our doula was on call, ever though it wasn't really close to my wife's duedate. For me, knowing our doula could be with my wife in case labor happened while I was gone, gave me a sense of comfort. 

1.       How hospitals work:  Hospitals are complex systems that practically have a life of their own.  Many different professions work together to create the beautifully synchronized dance that is a functioning labor and delivery ward.  The various actors all have their own roles to play and each one is important.  Nurses assess and monitor.  Patient technicians take vitals and help with repositioning and other essential tasks.  Doctors and midwives are responsible for the health and wellness of several mothers and babies at a time.  Anesthesiologists administer epidurals.  Even the housekeeping staff have an important role in keeping contamination risks at bay.  This doesn’t even take into account nurse managers, case workers, social workers, scrub/OR nurses and the hospital administrative staff.  If any part of the system isn’t perfectly coordinated, it can cause problems in many other parts of the unit.  My presence as a doula should not be a hindrance to how the unit operates.  In fact, it should add to the effectiveness of the whole team and knowing what everyone else is responsible for and keeping within my scope will ensure this.

In a large birth center, it is very easy to get lost in the hustle and bustle of so many people and so much activity.  I highly recommend that all doulas take a tour of any birth center that they are not familiar with prior to going there to support a mother in labor.  Ask questions about nurse to patient ratio and how many patient technicians or aids are usually on each shift.  Ask about their intake and triage procedure.  Ask if the labor and delivery unit is separate from the postpartum unit or if the mother will remain in the same room throughout her stay.  Orient yourself to the floor, making sure you find the ice machine, the family lounge, the restrooms, and the vending machines. 

2.       What L&D nurses actually do:  When I began my training as a doula, I had a false sense of what labor and delivery nurses actually did.  I assumed that they would be “hands-on” with the patient often, either by taking vitals or doing vaginal exams or other “medical” things that I only vaguely defined in my head.  In reality, most of their job consists of observing, assessing and documenting with a healthy dash of caring thrown in.  Nurses are the primary eyes and ears in the room for the doctor, midwife, and laboring mother.  She is the first one to notice if something just doesn’t look right and the first one to take steps to mitigate any problems. 

As doulas, our job is to facilitate a good working relationship between the nurse and the laboring woman.  Respect the nurse and the important job that she is doing.  Advocate for the mother’s preferences regarding monitoring and assessments.  Better yet, teach the laboring woman how to advocate for herself.  Make suggestions on how to meet both the need for monitoring and the need for freedom of movement, such as moving the birth ball to right in front of the machine so the wires will reach, using a wireless pack, or using intermittent monitoring instead of continuous.  Ask the nurse if there is anything that you can do to make her job easier.  Above all, remember that very few nurses went to nursing school because they like to chart!  These nurses chose to be in labor and delivery because they care about these women.  These nurses may see you as a threat because you are taking the best part of their job away from them – being the shoulder to lean on and the person who gives reassurance.  Let the nurse share in supporting the mother with you – that is a win-win situation for all parties involved.

3.       The rationale behind “Policy”:  The hospital, the doctors, the nurses, and doulas all have one common goal: the health and safety of all of the women and infants.  The hospital’s policies are usually a source of grief for my clients.  They are viewed as rigid rules that impose on their body’s ability to birth naturally.  I am not going to address any one policy in this section, just the reasoning behind these policies.  The hospital wants to ensure the safety of EVERY woman, not just one specific woman.  They know that for every so many hundred births, something will go wrong.  They address this by instituting policies on everyone to make sure that those few who will have something go wrong don’t get missed until it is too late.

Sometimes these policies are out of date or not applicable to a mother’s personal situation.  If that is the case, the mother can always opt out.  It is easier to do this if the mother knows the policies ahead of time and can talk to her caregiver about it, but it is never impossible.  (I know a woman who didn’t just change doctors, but changed hospitals at 8 cm dilated in active labor to avoid a policy that she didn’t agree with.)  For every procedure that is done in the hospital, the informed consent of the mother is required.  Informed consent mandates that the mother understands the benefits of the procedure, the risks associated with it and how likely they are, any alternatives to the procedure, what happens if it is not done, and any implications of her decision.  A woman always has the last say in what happens to her body!  To best advocate for your clients, make sure that they know how to advocate for themselves by asking the right questions, knowing where to look for unbiased information, and ensuring they have enough information to give informed consent or informed refusal.

1.       How I treat my body and my mind now matters:  The thing that prevents complications from developing during labor more than anything else, is not who she chooses as a care provider or what doula she decides to go with – it is how she treated her body in the years before she became pregnant.  Eat healthy.  Maintain strong muscles and healthy joints.  Keep your weight in a healthy-for-you range.  Try to squat sometimes even before you get pregnant, just to get used to how it feels.  Get enough sleep at night.  Get help for your anxiety or depression.  Learn what techniques help you to manage your stress.  Yoga is amazing because regular practice will build strength, flexibility, decreases stress, promotes relaxation, and most importantly helps to develop a trusting relationship with your own body.  You learn how to really think about and focus on your breath.  You learn how to be in and feel your body, how it is positioned, and how to reposition it in a way that it is telling you to.  These are all things that you can do now, even if you are not pregnant to ensure a healthy delivery later on.

2.       The time to prevent interventions is at the prenatal appointment – not in labor:  Talk to your care provider with an open-mind and realistic expectations.  Tell them what matters to you.  Ask them what the policies are.  Try to compromise between the two ahead of time.  There is no prenatal appointment that is too early to start discussing your birth plan!  If your caregiver agrees with you to modify a policy, get it in writing in your chart and ask to speak with the charge nurse on the unit regarding it.  The more the nursing staff knows ahead of time, the more smoothly it will go during labor and delivery.  If your caregiver isn’t willing to compromise with you, hear them out.  Try to understand if they have a different philosophy of birth than you or if it is a matter of safety and you should consider changing your point of view.  If you can’t reach a compromise or you just don’t like your caregiver – shop around for a new caregiver.  All of this is much more easily done before labor, than during and in between contractions.

3.       The importance of flexibility:  Things don’t always go according to plan.  When making a birth plan, remember this.  In fact, make two birth plans.  Plan A: my ideal birth.  Plan B: if it all goes to hell and I need an emergency cesarean birth.  The fact is that even with the ideal caregiver, the best circumstances, the healthiest mother, and an easy pregnancy things can still sometimes go less than ideal.  The world health organization recommends a cesarean rate of 10 to 15%.  This means that for 10 to 15% of pregnancies, a cesarean birth is safer than a vaginal birth.  So be flexible during labor, if things don’t go as you planned initially keep as many elements as you still can.  Ask to be allowed to have skin to skin after delivery.  Swab the baby with vaginal secretions to kick start his microbiome, if you are into that sort of thing.  Make sure your partner still gets the picture of the baby on the scale.  Talk to your doctor about how to still incorporate your personal customs and rituals into the birth.

Doula work made me fall in love with birthing women. The sacredness and magic that surrounds them as they work so hard to bring their babies into the world is intoxicating to be around. After working as a doula for the past seven years, I made the leap to enroll in nursing school, with the goal of working as a labor and delivery nurse for a while, then becoming a midwife.

I had no idea what nursing school would be like, only that it was extremely hard to get in to. I am now in the last week of my first semester, with four more semesters to go, and honestly, I can't believe I made it through my first semester. Nursing school is hard,  people told me. I had no idea just how hard it really was. But now I truly do.

As a doula, I have been right there when women who were so elated to be having a baby before labor began, suddenly expressed that they just couldn't go on. And I was there when, indeed, they did go on to birth their baby, despite all their doubts. They made it through the other side of labor and birth. It is this inner journey and challenge that I have witnessed so many times that has helped me get through this first semester.

I have often thought of the strength I witnessed as a doula, to get me through the tough days of nursing school. As I held on for dear life, going through the rollercoaster of emotions, joys, and challenges of becoming a student nurse, I drew some similarities between nursing school and becoming a mom.

Stage 1: Wow! I'm pregnant! (Or I can't believe I got into nursing school!)
When a mom finds out she pregnant, some great emotion is sure to overtake her, whether it be elation, surprise, sadness, or anxiety. At first she might not believe it's really happening, but eventually the reality settles in.

When I found out I got into nursing school, I cried. Getting into nursing school in California is no small feat. I was one of forty students to be accepted (out of 174 applicants!) and I was in total shock that I actually got in. I started dreaming and planning, and getting ready for the semester to start.

Stage 2: Wait, I didn't know I was signing up for this!
After the initial shock, joy, or acceptance settles in, the gravity of the life altering event which is motherhood is realized. Hopefully she won't get too overwhelmed by all of the choices, options, and decisions she needs to make as she prepares to go into labor.

My pride that I got accepted into nursing school was quickly forgotten as I settled in as a student. Beginning the first day, we had reading assignments and a presentation due. It became clear that yes, I had accomplished a huge hurdle by simply getting in, but the hardest part was yet to come.

Stage 3: I can not possibly go on any longer
This is the point at which moms who were planning a drug-free birth use all of their inner strength to just make it through the next breath. Thinking too far into the future leads to desperation and fear that it will never get better.

There were many a days this first semester when I just wanted to curl up into a ball and not deal with the stress, and the huge workload, and the pressure to not mess up during clinical. Some mornings I was in tears as I got ready for school, and I had to take a deep breath and not think too much about what was due the next week, and how I had to wake up at 4:30 in the morning the next day.

Stage 4: I did it!
Whatever her doubts, whatever her fears, she did it. Even if things didn't follow her carefully written birth plan, she accomplished what she set out to do: have a baby. The journey there was important, and she went through many travails to get there, but the fact that she herself grew a baby and birthed it is something no one can take away from her. She feels part of something bigger than herself -- a connection with all other mothers that have come before her and given birth.

Despite my tears, and my anxiety, and my mistakes, I have made it through my first semester. I have one more week left in my first semester of nursing school, and I have so much more respect now for nurses. My aunt who's a nurse recently told me "this will be the hardest two years of your life" and I don't doubt that she's right! But another nurse family friend told me "if you can make it through the first semester, you will make it the whole way."

Stage 5: Be gentle with yourself
New moms might feel lots of different emotions after the birth is all said and done. Maybe they are disappointed with how they acted, maybe they wish they could go back and do things differently. But then (hopefully) they look down at that sweet new baby, take a breath, and realize no matter how they did it, they accomplished a major feat. They deserve to be pampered, and they should know how strong and courageous they really are.

I've made mistakes this first semester that I desperately wish I could take back. But you know what? When I stopped hounding myself, and looked around at my classmates, I realized we're all making mistakes. That's the beauty of being a student. That's how we learn. I know I did my best.

Nursing school is indeed so much harder than I ever imagined it to be. I simply had no idea what to expect. I prepared for it, printed and read all my syllabi before class, had all my supplies in order, but there was simply no way to make this semester easier. There was no way to get around the stress and the emotions, I simply had to go through it.

Just as a mom must go through her labor, whatever twists and turns it takes her on, she will have that baby in her arms. And I will graduate with my Bachelor's of Science in Nursing and become an RN. I just know I will.