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Hire a doula because, when all is said and done, she is the only one at your hospital birth (besides your family and friends) who answers to you as her final boss.

Your midwife, doctor, and nurse are probably wonderful and probably they want to help  you achieve the birth you want. But midwives, doctors, and nurses who work in hospitals have to answer to a lot more people than just you. They have to answer their colleagues. If they manage births in an unusual manner, and in today’s world, “unusual” may mean “more natural” just because of the statistical realities of interventions, their colleagues can exert subtle or not-so-subtle pressure to get back in line. And they have to answer hospital review boards and insurance companies. Insurance companies have a lot of impact on our medical institutions. Since obstetricians are the most-sued doctors in America, you can imagine that insurance companies care how they are practicing!

But doulas do not answer hospital review boards or insurance companies. They answer to mothers. Doulas are there for mothers. It is their entire job. One hundred percent. They do not have to spend time during your labor inputting lots of data into computers. They are focused on how you feel.

So it is definitely a good idea to make sure that your entire birth team is on board with your birth vision. It’s a great idea to make sure your care provider can handle whatever comes up (even if that means transferring your care. Transferring is still great care.). But it’s also helpful to hire someone who answers only to you. When you look in her eyes for reassurance in your decision-making process, you can be certain that she is reassuring YOU. She is helping you make the best decision for YOU.

Do you have any stories that exemplify this? I’d love to hear them!

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Reason #1: A doula can relieve your partner in a long labor. Sometimes the tasks required of a partner during a labor can be impossible without backup support from a doula. A labor that lasts through several mealtimes or all your normal sleeping hours can wipe out not only mom-to-be, but her support team, too. Doulas can allow partners to take 20-minute naps (or in really long labors, two or three hour naps) and visit the bathroom without being worried about leaving you alone. I once played back-up doula for a long labor in which the first-line doula AND the father needed relief. They had been supporting the mom-to-be for almost 36 hours straight and neither the doula nor the dad had slept for more than about 30 minutes. I came in the middle of the night for a four-hour relief stretch. I barely knew this couple, but I slipped into the dark room and quickly learned how to give back pressure the way this laboring mother needed. Her doula and partner went to the lounge to sleep. Mom and I worked together without saying much, just in the rhythm of labor. She was handling her contractions well; she was just exhausted. She, too, slept in between sensations. At dawn, the doula and father returned and I said good-bye. The doula and father agreed to take one-hour shifts after that so that they didn’t burn out. The baby was born, healthy and beautiful, about six hours later.

As a post script to this story, I ran into this woman two years later and found out that she had become a doula herself. She said she was so amazed at the support the two of us had given her and her husband that she wanted to give that gift to other families. She gushed about how incredulous she was that I had come in the middle of the night to offer relief to her support team. It was nice to hear, but it was also easy to say, “That’s what doulas do!”

BTW: here’s a link to a “10 Reasons To Hire a Doula” article by Ann Douglas. They are all good reasons. Excellent reasons. But I am going to try to write down the “other” reasons here in this series. The reasons that it’s GREAT to have a doula, but that most people don’t think about until after the fact (or, often, until it’s too late!): http://www.ohbabymagazine.com/prenatal/why-doulas-are-a-moms-best-friend/

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Dear Academic OB/GYN,
I am new to reading your blog, but really enjoying it! The issue of “informed consent” is really a unique issue for us here in the United States. (For my blog readers, you can see Academic OB/GYN’s post on the surgical consent form which follows below or head over to her blog at http://academicobgyn.com/2011/06/20/on-the-surgical-consent-process/).

I’ve worked in Russian hospitals (as a midwifery apprentice and as an anthropologist) and in Canadian hospitals (as a doula) and their approaches were so very different in tone and feeling! There was no informed consent process in the Russian hospitals (in 2000-2001) and the process in Canada felt much more like what you describe at the end of your post: a friendly chat.

That said, I think it is a fault of how we all in America — doctors and patients, professionals and laypeople — imagine medicine that creates a problem. Doctors are people (I love reading books like “How Doctors think” or “Complications” to remind me of that!), but sometimes we all pretend that doctors are really computers. We do not expect human indecision or unknowing or, God forbid!, human error. We expect perfection. This is true in many arenas, not just medicine. Our culture is very black and white. If something goes wrong with anything, someone must be blamed. Shades of gray or the idea of joint responsibility don’t fit our cultural expectations so well.

Finally, I am not sure that all doctors are capable of talking the way you describe. Some are; many are not. It is not just the moment of getting a signature on an informed consent form that matters. How doctors talk (or don’t talk) with patients matters all the time.

At the last birth I attended as a doula, a medical resident took over from an experienced midwife when the baby’s heartrate was non-reassuring for too long. She never introduced herself to the woman giving birth or her husband. She cut an episiotomy and put in an internal monitor and started using a vacuum with not one word of explanation. There were several seconds of silence in between contractions, so it was not because of lack of time. My client will never see that doctor again in her life. That doctor will never know how her treatment felt to those of us in the room. But as the doula, I have listened to three conversations in which my client is trying to understand what happened to her “beautiful birth” in those minutes. With just a few words, I think my client could have had it all: medical help in a possible emergency AND a beautiful birth.

I do not even entirely blame this doctor. We have created a medical education system that penalizes many doctors if they try to be well-rounded, emotionally-intelligent, full human beings. Probably, if this doctor experienced a major obstacle in her personal life in her first year as an intern, she was not going to be given empathy, kind words, time off to relax and rejuvenate, understanding, etc. She probably faced a spoken or unspoken expectation to tough it out. What we reap as a culture, we will sow.

In Russia, there was certainly a divide between doctors and patients. But in one area, I watched with amazement at how quickly the barriers fell down. That was in the area of pharmaceutical treatment. Diagnosing was the purview of the physician; but treatment was often a mutually-negotiated conversation that occurred between equals. Why is that? Well, most of the doctors and patients shared a common, deep knowledge of herbs. Everyone at my birth hospital seemed to share a tacit understanding that herbs were the preferred method of treatment, if possible, and pharmaceutical drugs (like antibiotics, painkillers, etc.) were only a second option.

The entire culture expects urban Russians to spend time gardening and foraging in forests (for mushrooms, herbs, etc.) as a normal part of life. It’s the best way to spend a summer weekend in Russia! That ubiquitous hobby has a strong impact on the way that doctors and patients interact in the maternity ward. Many Americans hear me talk about this and immediately jump to attack the Russian medical system. I know there are problems there (as there are here), but my experience was in a beautiful, well-run birth hospital with intelligent, capable doctors, midwives, and nurses that boasts excellent outcomes. And, in this one arena at least, there was a model for doctors and patients being able to discuss treatment options as equals.

Those consent forms, I think, are supposed to remind patients that they share in a joint responsibility with their caregivers for their own healing. Perhaps they also remind physicians that interventions are never risk-free. But in the end I believe that real conversations between two real people are the best protection: from lawsuits, from errors, from decisions we later regret. Legal documents are a mere shadow of that human connection.

Here’s the blog post:

Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.


As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.

While this consent process is quite standard, it just seems a little ridiculous to me. Its a bit like asking your neighbor bring your son home from school, and having her say “we may get hit by another car, I might run a red light, we may run out of gas on a train track, there might be a meteor that hits the car and kills us all…. but don’t worry I am a good driver and your son will be fine.”
The fundamental reason we do these consents is that we believe that in some way they will protect us in a lawsuit if something bad happens. For example, let’s say somehow I transect a ureter in my patient’s hysterectomy, I can say “See – I said this was a risk of the surgery… it wasn’t my fault!”
But isn’t that a bit ridiculous? Is telling somebody that something bad could happen actually a defense if that bad thing does happen? In some cases a problem is truly random, such as the development of a pelvic abscess after a hysterectomy, but in other cases it is not. There is almost no situation in which I could cause a ureteral injury and have it not be a surgical error. If it happens, I did it – and it was a mistake. Ureters are damaged in about 1% of hysterectomies, but its not like they magically get injured in 1% of cases. In 1% of cases the surgeon makes an error.
When I was a resident I worked with one attending that thought along these lines as well, and had a very different consent process.
“We are doing X surgery because of X. I’m a good surgeon, and think I can do this surgery without a problem. You need to sign this paper or the hospital won’t let me operate. I think it will go well, but anything can happen, and if it does and you think its my fault you can still sue me.”
This all seemed very glib the first time I heard it, but I have to say I have always had a lot of respect for that attending’s honesty. He was telling it like it really was, even though it wasn’t necessarily the smoothest way to go about it. He was indeed a very good surgeon. His partners thought he was a bit nuts, though.
The trouble with the standard consent process is that it doesn’t deal with the real issue; errors do occur, and physicians cannot be perfect. By naming error-driven events as statistical occurrences, the process supports an expectation that surgeons will never make errors, and thus the corollary that any surgical error is a de facto breach of physician’s fiduciary duty.
Every time I do a standard consent process, I think about doing it differently. Perhaps something like this:
“We are doing X surgery because of X problem. I am well trained to do this surgery, and think I can give you a great chance at an good outcome. Your surgery is something I know I can do well, but I cannot guarantee that you will not have a problem. I can only guarantee that when I do your surgery I will be well rested and that my team and I will do our best.
Sometimes when bad things happen during or after surgery it is a random event. There are certain things we can do to reduce these events, and we will do those things. Another kind problem can be because a member of my team or I makes a technical error. While I do my best to operate perfectly, it is possible that I could make a mistake. I have occasionally done so in the past, and will no doubt do so again in the future. As I have always learned a great deal from these rare mistakes, I hope to think I will never make the same error twice. Fortunately, almost every error is recoverable, and I know how to make those recoveries. If we have a problem, I will be there to fix that problem and help you through whatever recovery is necessary. I will explain the problem to you, and if I know, I will explain how it happened.
(now sign this paper or the hospital won’t let me operate )”
I often wonder if the common legalese consent process we go through actually protects us. Ultimately, we are bound to meet the goal of “The Standard of Care”, and we don’t get to define that standard on our consent form. Lawyers love to say that this standard is readily viewable in any textbook, but in reality its pretty grey. The exact definition changes from state to state, but usually is defined as what another reasonably practicing physician of similar training and situation would have done in the same situation. Fortunately, reasonably practicing physicians of similar training and situation also make mistakes from time to time, and usually lawyers and juries recognize that. As long as one recognizes the mistake and does the right thing from there forward, usually one has a reasonable defense.
So let’s just say that up front. We are well trained, and we do our best. If we screw up, we’ll let you know that, and we’ll fix it. Now sign here.

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In my last post, I suggested that if you know a doctor, nurse, or midwife who has supported a woman well in birth that you send her/him a thank you note. EnjoyBirth commented that she always writes thank you notes when she is a doula and points out the positive things that hospital staff have done during the birth.

That is one of my secrets as a doula that should probably not be secret. I ALWAYS carry a pack of ten thank you notes in my doula bag. I write at least two myself and leave the rest for my client in case she wants to write some thank you notes t before she leaves the hospital. I usually bring some small gifts she can leave with the notes: chocolates or small lavender mist bottles (which are easy and cheap to make at home).

Thanking birth professionals for their work is good for everyone. Of course, we all know how wonderful it feels to be noticed and appreciated. 🙂 I believe it helps improve doula-hospital staff relationships, too. Many doctors, nurses, and midwives are happy to welcome doulas to birth teams and they know we have a lot to contribute. Some, as you may know, wish we weren’t there and go out of their way to make us feel unwelcome. I try to assume that they have had a bad experience in the past. Though my first responsibility is to the laboring woman who has hired me, I always strive to make allies out of the hospital staff if at all possible. I’d like to leave them with a positive impression of doulas. Thank you notes and gifts seem important in this regard.

Finally, no matter how a birth goes, I remember that hospital staff members have all dedicated years of their life to learning their craft, often at considerable personal sacrifice. Obstetricians have to spend a minimum of eight years, eight INTENSE years of more than full-time work (sleepless nights, on-call weekends, etc.) to become doctors. Because of the intensity of training, they have less successful marriages, fewer children (and often no children, ironically!), higher suicide rates, higher rates of depression and substance abuse. They also start being an independent practitioner with an average $157,000 of debt and must pay exorbitant medical malpractice insurance fees ($150,000/year on average and in some areas more than $300,000/year. Obstetricians are the most sued doctors in America.

I think of all they have given up — and yet how happy I am that they are there to back up normal birth in our country. I understand that it is hard for many obstetricians to support a natural labor without intervention. That is frustrating for all of us who love natural birth and believe that birth is usually safe. Yet even those of us who love natural birth know that there are some women and some babies who must have access to life-saving medications or procedures or face dire consequences. It is rare, I know. But I find that carrying gratitude in my heart for ALL obstetricians is good for me.

Those hospital staff members are there for us in our hour of need and for that I am grateful. It doesn’t mean that I intend to use their skills unless I really need them. As a doula, I help most of my clients learn how to say “no” to many, many common interventions. Still, it works better when we say “no” with humility and gratitude.

Thank you notes are just always helpful and never hurtful. I recommend thank you notes as a hospital “intervention.”

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If you are a doula or any other sort of birth professional, run do not walk to your nearest book source to get “Survivor Moms” by Julia Seng and Mickey Sperlich. I happen to live in Ann Arbor, Michigan, the hippest place in the (sort of) Midwest, and Ann Arbor is home to many amazing midwives, doulas, and obstetricians. Really. We have at least FOUR awesome obstetricians in our town and those are just four whom I know personally. There might even be more than four, which definitely puts us in “hippest” territory. Anyway, Ann Arbor is where Julia and Mickey lives so I have the pleasure of knowing Mickey and Julia personally.

“Survivor Moms” is the book I didn’t know I needed when I was a fledgling doula. I supported many new mothers on their birthing journeys and left the births shaking my head. What happened there? I would wonder. Someone who said she wanted one thing turned into a completely different person in labor. Or she got “stuck” at some point in labor and we just couldn’t shake it. Then she would cry and shake all over and labor would get going again. Huh? Or her mistrust of the hospital personnel was so huge that it took over labor. Keeping nurses out of the room became the only way to keep the mom from getting hysterical.

I knew the stats, like any feminist should. I knew that many women experience childhood sexual abuse and/or date rape and/or domestic violence with their partners. The thing is, I just didn’t connect the dots the way I should have. I didn’t think deeply about how these experiences could impact birth.

One client for whom I was a volunteer doula clarified it all for me, though. I knew about her heartbreaking childhood and I could see that trusting anyone (myself, included) was an act of heroism on her part. I watched the nurses react to her mistrust as if she were an imbecile. She succeeded in having a natural hospital birth, but I can only describe the battle with her two nurses as a war. We were all wounded by the end.

This book, “Survivor Moms,” is the book that I wish I had read before that birth… and before so many others. Now that I’ve explored the wisdom offered here, I shudder at the thought of thousands of nurses and obstetricians blithely attending women in birth without a single thought to their sexual history. When women have survived unspeakable violence to their sexual selves, it can have a tremendous impact on their labors.

But what I appreciate most is the call for non-judgement. Some survivor moms need support to take control of their bodies in ways that natural birth advocates do not always readily support. They may need to schedule c-sections in order to feel in control of their sexuality and reproductive selves. They cannot bear having strangers gazing at and touching their genitals. A c-section feels empowering. And other survivor moms need support to be as in control of their natural, vaginal birth as possible. They may need to refuse vaginal exams, for instance. These moms may find birth healing, as they use wounded parts of their bodies and souls to produce goodness and new life. As a doula, I feel better prepared to provide this support now that I’ve read what dozens of survivor moms have to say about their birthing experiences. I love this book!

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