I arrived home at midnight after being with my client, Marie, for 18 hours. The house was still and dark, thankfully, with all my boys asleep. In need of support, I emailed my doula mentor, Lisa.
“Would it be totally out of line to somehow let a potential client know I don't wish to work with her practitioner?” I gave Lisa the back-story, pressed send, then crawled into bed.
My own back-up doula loved this practitioner and admitted she found solace and security within his office during her second-trimester experience of loss. Marie was my 5th birth with him, and although I had faith in her education and motivation, I had some underlying feelings I could not deny: Four of those five previous clients had ended up with cesarean births, and the situations were similar, in that they were failed inductions.
As Marie’s due-date approached, her practitioner kept suggesting an induction. When she declined, he had her come to the hospital for non-stress-tests and biophysical profiles every-other day. As far as the tests showed, Marie’s baby was happy and healthy, enjoying life within the salty sea of her mother’s womb. The hours spent at the hospital were frustrating for my client. She was not able to rest and relax during the last days of her pregnancy, and her practitioner kept phoning her at home, scheduling more tests, insinuating that she needed to keep the baby’s health in mind, but then always ending his calls with, “But it’s your baby…”
Six days past her due date, he asked her to meet him at the hospital at 6 pm so he could check her cervix. When Marie’s practitioner arrived, he asked her mother and her husband to leave the room so he could examine her. Unsure of hospital protocol and their rights, the two stepped out of the room. When they were brought back in, Marie had already received Cervidil to begin an induction. She made the decision in haste, feeling pressure from her caregiver, but she acknowledged and accepted her choice.
I joined Marie and her husband, Craig, at 4 am. Marie had been vomiting for an hour – her body’s response to the pain was to vomit…and vomit…and vomit. At one point she said, “I just need to stop throwing up!” She did not get any rest that night. The next morning she requested Nubain, and then later, an epidural.
At about 3 pm, she began Pitocin. Marie and Craig’s baby did not tolerate this well, and the Pitocin had to be turned off. Marie’s practitioner said a cesarean would be their best choice; less-optimally, he added, was to give baby a break and try to continue the Pitocin, “But I am not hopeful that will work.”
Marie was devastated. “When I came to the hospital yesterday, I knew this was going to happen – I knew I would end up here, and yet I did it anyway.” She sobbed, she vomited, she let everything out she could. Craig and I sat close -- touching her, holding her throw-up-bucket – and listened to her pain. After a while, she was calm enough to seriously approach her options. Although I could not make this decision for them, I let them know they would have my full and unconditional support, whatever they chose.
All of this took about an hour. Craig and Marie decided to try the Pitocin again. She was at 5 centimeters, her epidural was providing adequate relief, and she felt with one more shot, if the baby continued to show signs of distress, they would know without a doubt a cesarean birth would be warranted.
Amazingly, Marie and Craig’s baby showed no more signs of distress. She had the normal peaks and valleys medical practitioners like to see in response to contractions. By 9 pm, Marie was instructed to begin pushing. Her practitioner came in, tried to guide her through, and then 20 minutes into it, left abruptly without a word to Marie or Craig. They were confused and felt like something was wrong, but the three of us continued our routine.
Marie’s practitioner came in about 30 minutes later, checked her again, and stated, “Baby is still at -1 station. You haven’t moved her at all.” He did this with no emotion, no encouragement, no trace of hope in his voice. Marie became almost hysterical. To know her strained efforts in pushing her baby had done not one bit of good was too much to bear. “Looks like it’s time for a cesarean. You can talk about it. I will be at the desk.” And he walked out of the room.
“I can’t do it, Craig – I can’t do it anymore.” By this point Marie was hooked up to no less than ten tubes, wires and an oxygen mask. She had been awake for almost 40 hours straight. She had been riding a constant roller coaster during this whole process –- in fact, she admitted later, since her 28th week of pregnancy when her practitioner first suggested she may need a cesarean birth. Beyond exhausted, I had noticed for the last few hours her eyes literally looked like she needed toothpicks to hold them open, like in the cartoons. She had been vomiting again for the last two hours. Marie had reached the end of her rope.
“Marie, this is where you wanted to be – 10 centimeters! You need to just get angry, get mad, and push this baby out!”
I have never said that before during a birth -- “Get mad!” In the heat of things and my own exhaustion, it just slipped out. She shook her head.
This woman, this was not the same woman who sought out my doula services at 18 weeks of pregnancy. This was not the woman who read every good book she could find, books by Henci Goer, Ina May Gaskin, Marsden Wagner, Michel Odent, Penny Simkin. This was not the woman who watched The Business of Being Born and praised the information and prepared herself for a safe birth in the hospital. Where was that woman now?
Marie, the real Marie, was replaced by Marie-the-Exhausted, like a saint, or the title of a painting. Is it any wonder? Unlike a saint, or an objet d’art, Marie was a woman – a real woman -- trying to have a baby, right now, in the present. And to her perception, it was not working.
The information of her small amount of progress during that uncoordinated pushing was left out (she started pushing at 9 ½ with a very heavy epidural, and now she was completely dilated). When she asked, after her progress report, if there were anything her practitioner could do to help her push better, he said, “We could turn the epidural down so you can feel more pain -- ” To which she responded by vigorously shaking her head, like a toddler about to melt-down: “No. No. No. No. No. Don’t turn the epidural down!”
Craig went to tell their practitioner what they had decided. The practitioner came in, patted Marie on the head and said, “You ready for your cesarean then? I’ll go get the OR ready.” That was the first kindness extended to her in 40 hours – maybe 40 weeks! -- from the professional she trusted to care for her and her baby.
As things were being prepared for the birth, I was fighting back tears, telling myself over and over, “It’s not about me, it’s not about me, it’s not about me!” I watched Marie as she seemed to go deeper and deeper into herself in order to cope. I stood by, mopped her brow, held her emesis basin, and mentally absolved her from any judgment I may have felt for this choice. But I also detached, I know I did. I tried not to let this mother see it, but my heart stiffened and clouded over for what was happening here. And it scared me.
Baby was born safely with apgars of 10 and 10 (to which someone happily exclaimed, “Babies never get 10s!”). I stole a glance and a touch of the baby, hugged Craig, kissed Marie’s cheek quickly in the recovery room, and then left, much to the urging of her family and the hospital’s post-op policy. I walked out in a daze, unsure of what I was feeling.
That night, I had a dream about a swimming pool I used to frequent as a child. When I awoke, the image of that 22-foot deep end was still lingering in my mind. I realized something: Being with someone as a helper and observer during birth, you see many facets of the experience -- it's like you see down 20 of the 22 feet into the bottom of the pool. What must be determined is, how far into the water the mom sees. If she only sees 5 feet down, or 12 feet down, then that's where you must frame your references – you can’t go below her established depth, because it would do harm and not good. Even though I can almost see the bottom, if she can't, there is nothing to be gained by describing it to her. Throwing that stuff out there to her, without her asking specifically, would be a way of trying to comfort me -- it then would be about me, and not protecting her memory of the day her baby was born. How does this look in real life? When a doula brings up something that really bothered her, when she questions a decision the family made, when she offers her opinion about something the mother didn't bring up or seem bothered by -- that's when she casts doubt about the bottom of the pool the mother saw and basically tells the mother she is wrong.
So I shoulder and table a lot of things I remember and felt during her birth, which every doula should do.
Back to the question I asked of my friend: If I were approached by a woman interested in hiring me, and she had this practitioner, what would I do? Ethically, could I say no? To make matters worse, a week before Marie’s birth, I had committed to a client in just that position. I felt firmly lodged between a large rock and a very hard place.
The first (and easiest) option would be to inform the woman that I have not been comfortable working with that practitioner in the past, and to refer her to other doulas. Lisa cautioned, and rightly so, that this would need to be done in a gentle, diplomatic manner where I was not breaking the woman’s confidence in her practitioner.
The second option is a little trickier: I would tell the woman I am not the best doula for her situation. If this elicits more questions from the woman about why, I could ask, “Would you be interested in a few questions you could ask your practitioner?” Lisa shared, “Answers to how often he induces, augments, or performs cesareans may be revealing to the woman and can empower her to make her own choice as a result of her own research.”
The third option would be to put my personal feelings aside, just say “yes,” but with a motive: Taking this on as a personal challenge to help a woman have the best birth memories possible despite the way her care practitioner shapes the experience. “In this case,” Lisa said, “you do leave yourself more open to burn out.”
Remember the “It’s not about me” mantra? I have come to realize some element of this work does have to be about me. I love being a doula, and to keep my passion kindled I have to get even the tiniest bit of personal fulfillment out of it. There needs to be no guilt about this act of self-care and love. The doula/client relationship is similar to that of mother and newborn: There is a fierce desire to protect and nurture – the ratio is often 99 to one as far as what a mother gives to what she gets, and sometimes it’s about the same for a doula/client relationship.
It has been 10 years and many moves since this birth, but what did I chose to do? Out of Lisa’s suggestions, I did not feel one perfect fit, it more depended on how fit I felt. I would listen to the woman. I then assessed where I was emotionally and professionally. And then I would act accordingly.
Six months after Marie’s birth, I got an inquiry from a woman who had this practitioner. “This is our first baby. We have Dr. P., and we would really love to have your help through this experience.”
Guess what? I said “Yes.”
When someone says, "At least I have a healthy baby," how do you interpret she feels about her experience? Birth is a transformative experience, and women can be transformed for the better, or for the worse. How can we, as doulas, help support someone who has had a traumatic experience? Abby gives excellent ideas which remain within our scopes and roles as doulas.
When you look at the probability of trauma in the course of a woman’s life, the statistics are high. One in three will experience sexual abuse in her lifetime, one in four will perceive her birth as traumatic. So, if you’re a childbirth or postpartum professional, you are regularly working with women who have experienced trauma. And keep in mind: a woman who has previous trauma or a history of abuse has a much higher chance of being triggered in birth and experiencing trauma again.
What is birth trauma? It’s all about perception. When a woman perceives her birth as traumatic, she has felt one or more of the following in an intense and damaging way:
Birth trauma will have immediate effects on a woman and change her experience of birth, postpartum and motherhood. As birth professionals, our goals are to prevent birth trauma by providing support, information and guidance for laboring Mamas. Some of the things you can do during your time together are build trust, tune in to Mom’s behaviors to establish safety in the labor room, and speak to her in a calm, affirming voice. But unfortunately, we can’t always prevent birth trauma.
Women who have experienced a traumatic birth can develop PTSD (posttraumatic stress disorder). It can be misdiagnosed as postpartum depression or anxiety but the symptoms are actually different. Some signs of PTSD in a new mother are:
There are some important things to keep in mind when dealing with a Mom who has birth trauma. Your support will be critical to establishing safety, support and eventually healing from this difficult time.
Here are some things you can do to support a Mom with trauma
The exciting and encouraging thing to hope for is what’s called post traumatic growth. With proper self-care, nutrition, sleep, and exercise she will begin to feel better. Suggest to her that some women find healing through yoga, body work, trauma therapy and groups. Post traumatic growth provides women the opportunity to heal from trauma and become stronger, wiser and more compassionate because of it. With adequate support, education and care, new Moms can fall in love with their babies and leave the shame and pain of trauma behind.
Abby Bordner’s background is in medical settings, community education and entrepreneurship. She currently has many online and in person projects for the non profit sector and her private business. She is a Cappa Doula Trainer, Labor Doula, and Lactation Educator. She is a certified ICEA Childbirth Educator, as well as an author and entrepenuer, creating such projects as Yoga Born, Birthing Tree Cooperative, Relationship Based Parenting, and Modern Motherhood. She travels around the US providing certification training for future Cappa doulas, and Yoga Born Childbirth Preparation classes – trainings for prenatal yoga instructors which integrate yoga and childbirth education.
I love how Liz is thinking outside the box here. She truly shows the progress in her beliefs as life has shown her more. As doulas, it is pretty easy to become disenchanted with doctors -- on a surface level we see and hear things -- and often judgements are held. Liz's world shifted when she looked deeper into the issue to see what women physicians face. Think of what it might be like if these physicians were offered physical, informational, and emotional support during the child-bearing year? And how it could help to improve not only their health, but also the health of those they serve?
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.
Liz Langthorn, Master of International Maternal Child Health from Tulane University, current medical student at University of Oklahoma College of Medicine. Once a birth doula, always a birth doula.
I was 14 when my little brother was born. One day he fell down, like kids do 800 times a day, and he began to cry. I said, "You're fine, stop crying." My mother replied to me, "You don't know how he feels." And you know something? She was right. Ever since that situation it has stick with me: I don't know how others are feeling, why do I feel the need to tell them? I believe this also applies to birth trauma. When we tell women they should just be happy with their babies, no matter what she experienced during birth, we are telling her how to feel. And guess what? We don't really know how she feels. But something we need to realize: her feelings are appropriate and authentic, and they are not wrong. Allison's insight into this world of loss and grief might be difficult to read, yet I am hopeful we can begin to change this.
So here it is, my first blog. I’m writing it from my gut, my heart and my mind last. It comes from the words “Well at least you have a healthy baby,” and the response from women, “I guess I just have to get over it (birth that is)”. Writing those words, let alone hearing or speaking them is like the thunderbolt out of nowhere. There is no silver lining to that thunderstorm. Those words have trauma and loss written all over them as well as an absolute lack of empathy. Where has this notion come from? How on earth has society become so warped in its beliefs about birth and the well-being of women who birth our next generation? Words may be transient but their impact is not, the impact hits hard and over time, women believe such words to be true. Such words could not be further from the truth, yet the truth lies in their devastation.
Birth is a forgotten rite of passage. Women come face to face with their raw vulnerability, strength and power as they walk through the gate of maiden to mother, yet somehow the significance of this experience has become lost and is dismissed within our society. Since having my babies I birthed a new life motto that completely throws this notion out with the bathwater – “Birth has the power to make, break and save our soul”. This I know to be true as I have lived all three. The words of women I have walked with through my birth work also resonate with this belief, yet they are silenced. They have a healthy baby. For some, behind their smile they hide a turmoil of feelings, thoughts and emotions screaming to be let out – their baby may be healthy, but their mind, heart and soul are not. The way in which a woman FEELS about her baby’s birth is as significant, if not more so, than the way in which her baby was born. The latter of course is important too, but that’s a whole other blog.
Birth trauma and loss, the Pandora’s Box of the birth world. A box that I feel ready to open, pull apart and challenge. So, what is birth trauma and loss anyway? It is way more than the devastating obvious physical pain, the flashbacks, anxiety, depression or the birth that required emergency or medical intervention. Look deeper inside the box. Birth trauma and loss lies in the eye of the beholder. It has many faces, often subtle and hidden in places too often overlooked, with even the birth that appears “perfect” hiding a life changing unspoken secret. It is the insidious nature of the maternity care system (for those that work within it and those who receive its services), the complex politics, the “one size fits all”, the outdated policies, the power imbalance, the conformity, choices that are not informed, the loss of control, the maternal request that provokes anxiety, the bullying, the care provider or mother who is silenced, the scaremongering, the withholding of information, the coercion, the words that are said or are never said, the disapproving glance, the tut or the sigh, the tick-tock of the birthing clock, technology that replaces instinct and interaction, the medicalisation of birth that interferes with mother nature’s birth dance, the thinking brain, the fear, the adrenaline and the “cascade of intervention”. The list is endless, the contents of the box different for every woman, creating a picture that is etched within their soul, changing over time through varying shades of darkness and light.
Birth trauma and loss is a journey of self-discovery, grief and ultimately I hope, strength and transformation. So for all women, “getting over it” is not an option. Living, exploring and releasing themselves from their birth experience with forgiveness is a very real and necessary option. So instead of “Well at least you have a healthy baby”, next time you are in the presence of a new mother, listen instead of speaking. Show compassion not sympathy. By listening and watching we hear a thousand words. I end with another motto –“Birth is all encompassing, physical, emotional and spiritual. It imprints on a woman’s soul and from the moment it occurs, a woman is forever changed”.
So who looks after the maternity system that looks after the care providers who look after the women who birth our next generation? The answer is ALL OF US. It is time to challenge society, to choose our words wisely and to bring birth back to women.
Dig deeper into the box.
Allison Tate is the mum of three boys, a birth and bereavement doula, and a childbirth educator serving families in the Edinburgh, Scotland area. She co-facilitates the Positive Birth Movement Group in Edinburgh and the Lothians, and is a member of the Lothian NHS Maternity Services Liaison Committee. She is a volunteer buddy with Bliss Scotland, and works closely to support bereaved families with SANDS Lothians. Allison celebrates and recognises birth as a physical, emotional and spiritual experience and by empowering women through access to information, nurturing their innate wisdom and inner strength to make their own informed choices about their pregnancy, birth and early parenting (without fear of judgement, bias or misinformation) birth is rightly owned by each mother. Back to Birth is her website -- also look for her blog.
♥ four young boys and a boy dog (offspring)