Day 14: Things I Wish I had Learned...

5/14/2015

Here is another take on a doula's experiences in nursing school. Amanda offers insight into what she has and hasn't learned in her different educational pursuits, and I, for one, was surprised by the results. These are excellent points to keep in mind as we work with families and with nurses.

Things that I learned in nursing school that I wish I had learned in doula training:

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.

Things that I learned in doula training that I wished I had learned in nursing school:

1.       What labor and birth look like without intervention:  This may or may not come as a shock to you, but in the course of my Nursing Care of Women and Children class we did not once see an unmedicated labor. All of the videos that we watched in class were of women who already had an epidural in place. At my placement site for the clinical portion of the class, more than 90% of women had epidurals. The 10% who didn’t, were usually attended by midwives instead of obstetricians who didn’t allow students in the room. In a four hour lecture on caring for women in labor, we spent 15 minutes on managing labor pain with opioids, 45 minutes on epidurals and the nursing care involved, and less than five on all non-pharmalogical methods combined.

This seems to me to be a chicken or an egg type of a conundrum. Do we spend more time on epidurals because that is what most women choose? That makes sense to the practical side of me. Of course we need to learn how to care for women with epidurals, and if that is the majority, then shouldn’t we spend the most time on that? But what if, we as nurses, unconsciously push for more epidurals because that is what we are the most comfortable with?

Obviously, I can’t speak for anyone’s experience besides my own, but if I had not been a doula prior to nursing school, I would have never seen an intervention free labor. I am in the camp that believes that birth is not pathological and that we should not intervene unless there is something going wrong, so the idea that there are practicing nurses who have never seen one without intervention seems unusual at best. Therefore, I would like to see a more comprehensive nursing curriculum that covers non-pharmalogical pain management and an intervention-free labor more in depth, even if it is just a film.

2.       The importance of the psychological state of the mother:  Birth doula training focused on this topic extensively. Human women are just like all other mammals in that to give birth we need to feel safe and secure. That just makes evolutionary sense: a woman in labor is vulnerable and so is her infant. Any increase in stress during early labor can stall progress. Additionally, fear and anxiety are well known to be associated with tension. Tense muscles during this time when the mother’s body needs to relax and open up can increase the amount of pain that is felt during labor.

Birth doulas use this knowledge and spend most of our efforts trying to reduce stress. We create an atmosphere of peace by dimming lights and playing soft music. We empower a woman to feel like she is in control, even when her body is listening to more basic instincts. We are the gatekeepers for mother-in-laws and supporters of partners, so she is free to worry about a few less things.

Nurses could be a huge ally in this process. They are gatekeepers of a different kind. They can cluster tasks to minimize interruptions or space them out if the woman needs a distraction. They can knock before entering the room and insist that others do so as well. They can protect the space better than doulas can, by making sure that other hospital staff do not come in to refill supplies or empty the trash. Nurses also have the importance position of being the intermediate between the hospital and the laboring mother. Orientation to the room and floor is essential to feeling secure. It is amazing how much difference knowing where the family lounge, the bathroom, and vending machines can make. Listing the names of the nurse, the patient technician, and important phone numbers somewhere in the room can give the mother a sense of belonging and welcome.

3.       Physical support of a woman in labor: The birth doula workshop is truly an amazing experience. I didn’t just learn about how to physically support a laboring woman, but also how to ask the right questions to figure out which skills would work best for that particular woman. From using eight pillows to ensure that every single joint was in alignment and supported, to applying firm counter pressure, to a cool wash cloth placed on her forehead, doulas have the market cornered on providing physical comfort.

This starts with a solid foundation, which nurses are already taught, the gate theory of pain. Simply put, a person’s brain is only capable of paying attention to so much information at a time. Overwhelming these nerve pathways with other stimuli, like cold or pressure, prevents some of the pain from getting registered. Nurses learn about this theory early on in their education because pain control is an important part of our everyday tasks. The application of this theory in labor is, however, as I mentioned above, taught in a very limited manner. Furthermore, reading a laboring woman to determine which of the comfort measures to try is not taught at all.

Things that I am grateful that I learned in both because I also have a uterus:

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.

Amanda currently works as a birth doula for Shining Light Prenatal Education to make birth better for the women in the greater Pittsburgh area. She is also a “second-degree” nursing student at Duquesne University and will graduate with her BSN in July of this year. She is passionate about informed decision-making and self-determination in the birthing suite and beyond. When not attending births or studying, Amanda practices yoga and takes long walks with her dog.

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