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Not everyone who is having their first baby had a wedding first. If you did, though, you have a natural window through which to peek at your relatives’ likely behavior — and your likely feelings about their behavior — at the birth of your baby. If you did not have a wedding, you may be able to think of another emotionally-heightened event at which family play a big role that will act as this window.

Mothers, mother-in-laws, sisters, and close friends are all likely to want to play a role at the time you give birth. I will focus mostly on mothers here, although for any mom-to-be it may be a sister or friend who lives nearby who is the focus of your attention. The question that pregnant women often ask their doulas is, “Should I invite her to the birth?”

If the woman had a wedding, this is where I usually start my questioning. Because it’s not about whether the relationship itself is good or bad. If you are considering inviting this person to your birth, I will assume the relationship is at least pretty positive. It’s about how the woman feels when she is doing something meaningful, stressful, and full of rapid decision-making in the presence of this other person.

Did you feel like your mother (sister/aunt/friend) understood exactly what you needed in the moment and was acting like an extension of yourself at all the wedding events? Or did you feel like she kept bringing you problems and issues to solve? Did she love your ideas and offer to help out anywhere? Or did she disapprove of your decisions (subtly or not so subtly)? Did she try to talk you out of ideas that meant a lot to you? Did you feel like her feelings enhanced and deepened the meaningfulness of your wedding for you? Or did her feelings about your wedding interfere with your own enjoyment?

 

Mothers can be just like us or very different from us and still be capable of offering genuine support. But not all mothers can offer genuine support. Their own needs get in the way of that.

Take a good look at how you felt about your mother (sister/aunt/friend)’s role at your wedding. If you have any lingering feelings of resentment or disappointment, I would strongly urge you to find a way to keep your laboring space free of their presence. Give her an important job to do away from your birthing space (making a birthday cake for the baby is a great job, for example). You do not get a re-do on your birth experience, so, like a wedding, it’s important to plan carefully. Don’t discount this treasure trove of information about how people are likely to act. Together with your gut instinct, this information about the past can usually tell you what you need to know about, “Should I invite her to the birth?”

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POST-PARTUM SEX By Cynthia Gabriel, Ph.D.

No one talks about the sex life of new parents. I could make a joke here about how that’s because there is none, but that is not true at all. We would just rather gossip about a celebrity’s sex life than talk about real and challenging issues in an open, accepting way. Here in this land of individual freedom, we just let people figure things out (I mean struggle) by themselves. But it doesn’t have to be this way!

I, myself, have struggled with my sexuality in the wake of becoming a mother and I could have used some advice and reality checks. I feel lucky and privileged to have talked about this intimate subject with hundreds of women in interviews and in mother-baby groups. So, from the get-go, let me acknowledge that this is a one-sided piece. I have only heard from a handful of new fathers and even fewer lesbian mothers about this issue. But from these new mothers, I want to share some observations.

Friends, family, and medical professionals may assume you haven’t had sex in a LONG time – as if pregnancy and sex were incompatible.

Although pregnancy does slow down a sex life for some couples, for many couples pregnancy is a time of great sexual exploration. Still, birth has a way of changing the sexual dynamic, even if you were enjoying yourselves fully just a few days or weeks ago.

It takes longer to have sex after the baby is born for many couples than you think. Many people assume that the six-week mark is some magic date because there is usually a check-up at six weeks with a doctor or midwife. Yes, one of the topics of conversation at this check up is supposed to be birth control and, yes, the medical professional will examine the perineal area and the abdomen for healing. But this does not mean that a magic date has arrived. Do not think for a moment that MOST people have sex sometime around the six-week mark. Some do. But many, many, many do not.

The first time you have sex after having a baby is more of a “check in” than an act of passion. This may continue for a while.

A woman often wonders what sex will feel like after having a baby, even if she gave birth by cesarean. “Things” feel different in her body and it’s not clear ahead of time how these new sensations will affect sex. Lactating women are probably experiencing leaking and spraying as part of their everyday lives and they usually worry about how this will affect the sexual experience. She may have relied on nipple stimulation in the past to help get to arousal. What if her nipples are too sore from a baby’s mouth to be played with like they were in the past?

If you go into the first time – and, realistically, the first five or six times – as experiments, you will be less disappointed. These are occasions to figure out what is going to work for you, not occasions to measure something about your sexual success.

Women are often deeply worried about how their partner will “see” them now. They NEED reassurance, but part of that need is not wanting to ask for it.

The partner probably needs and wants reassurance, too. The partner wants reassurance that s/he is still desirable and that the new birth mother is not so wrapped up in the infant that there is no room for their “couple-ness.” The bad news is that the new birth mother is in NO POSITION to offer this reassurance. She will be able to do this better when the baby is one year old and she is feeling more confident herself. But right now, these first MONTHS (that’s right. Months. Not weeks) she is the one who needs reassurance. It’s part of the trade-off about growing the baby and giving birth to the baby. So, no matter how much you wish she would tear your clothes off and tell you how sexy you are, now is the time for you to tenderly reassure her that you find her attractive AS SHE IS.

Getting annoyed at the baby is a TURN-OFF. Being understanding of her attunement to the baby is a TURN-ON.

If you manage to get all the things in order to have a sexual encounter (you are rested enough, had a shower, the baby is asleep, the bed is not full of baby poop or throw up, you are not mad at each other about who got up in the middle of the night for burping, etc.) and the baby wakes up and interrupts you…

If you can be understanding and caring toward your partner if she needs to take care of the baby (or if she asks you to do so) you are more likely to get another shot at this the next time the opportunity arises. It might be in five minutes, when the baby is calm or it may be another day.

If you groan and complain, you are less likely to get that second shot.

The choice is yours.

Figuring out WHEN and WHERE is more complicated than you think.

Some babies sleep enough that it’s possible to have a good sex life in your own bed. But many babies do not sleep enough and couples have to figure out where to go to have sex. The problem is that most babysitters come to YOUR house. If you can afford it, think of a hotel room for an afternoon as the same price as dinner and a movie. Once a month, this may be worth it.

Sex can hurt more after having a baby.

Although this is not true for all women, for a certain percentage of women sex after giving birth is more painful than it was before. Generally, the first thing to try is more lubrication. If that does not fix the issue, an estrogen cream can be helpful. This is a topical cream, not an estrogen pill that you take internally, so it does not have the same effects on your body that hormone pills do. In studies of “women’s sexual health after childbirth” about half of women report vaginal dryness as an issue. You are not alone!

Feeling “Touched Out” is a real problem for new mothers.

 Many new mothers who spend their days and nights caring for needy newborns want to spend their non-baby time not being touched. It’s a serious mismatch for new mothers and their partners who, likely, are feeling less touched than they were before the baby arrived.

There is not an easy answer to this problem; however, if you are the partner reading this essay, I would take away that providing down time without the baby is likely to be helpful to the new mother’s receptiveness to touch. Otherwise, this is an issue that just requires patience and understanding.

For you science geeks out there I am going to copy some information from a 2000 British Journal of Obstetrics and Gynecology about this issue. What I find fascinating is that the medical professionals write it this way “Sexual morbidity increased significantly after the birth: in the first three months after delivery 83% of women experienced sexual problems, declining to 64% at six months, although not reaching pre-pregnancy levels of 38%.”

I would reframe it this way:

Most of us hope that we will return to our pre-pregnancy sex life by about six weeks after our babies are born because this is what we are led to believe by birth books and doctors. The reality is that this expectation is not realistic, but no one talks about it openly. The truth: 38% of us have sexual difficulties even before we have babies and 83% of us are not having the same kind of sex life we used to have for THREE MONTHS and 64% for SIX MONTHS after our babies are born.

In other words, it is NORMAL to have a very different kind of sex life for a LONG TIME after our babies are born. It is UNUSUAL to return to an easy-peasy sex life within six months post-partum.

INFO FROM THAT STUDY:

BJOG. 2000 Feb;107(2):186-95.

Women’s sexual health after childbirth.

Barrett G1, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I.

Author information

 Abstract

OBJECTIVE:

To investigate the impact of childbirth on the sexual health of primiparous women and identify factors associated with dyspareunia.

DESIGN:

Cross-sectional study using obstetric records, and postal survey six months after delivery.

SETTING:

Department of Obstetrics and Gynaecology, St George’s Hospital, London.

POPULATION:

All primiparous women (n = 796) delivered of a live birth in a six month period.

METHODS:

Quantitative analysis of obstetric and survey data.

MAIN OUTCOME MEASURES:

Self reported sexual behaviour and sexual problems (e.g. vaginal dryness, painful penetration, pain during sexual intercourse, pain on orgasm, vaginal tightness, vaginal looseness, bleeding/irritation after sex, and loss of sexual desire); consultation for postnatal sexual problems.

RESULTS:

Of the 484 respondents (61% response rate), 89% had resumed sexual activity within six months of the birth. Sexual morbidity increased significantly after the birth: in the first three months after delivery 83% of women experienced sexual problems, declining to 64% at six months, although not reaching pre-pregnancy levels of 38% . Dyspareunia in the first three months after delivery was, after adjustment, significantly associated with vaginal deliveries (P = 0 x 01) and previous experience of dyspareunia (P = 0 x 03). At six months the association with type of delivery was not significant (P = 0 x 4); only experience of dyspareunia before pregnancy (P < 0 x 0001) and current breastfeeding were significant (P = 0 x 0006). Only 15% of women who had a postnatal sexual problem reported discussing it with a health professional.

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Hire a doula because…

She will come to your house. None of the rest of your hospital birth team will do that.

If you are planning a hospital birth, one of the hardest decisions is “when to go to the hospital.” Your doula will come to your house in early labor and help you decide when is the right time to head to the hospital. Believe me, you will trust her judgment in this far more than you will trust your partner’s (unless s/he happens to be a birth professional!). This important decision can affect how you how your labor progresses and how many interventions you may encounter.

Most women go to the hospital TOO EARLY in labor! There’s nothing worse than getting sent back home in early labor.

Why do we go to the hospital too early? Because we all want to believe that we have progressed further than we have. When we have experienced labor for three hours, we want to believe our cervix has dilated to eight centimeters and delivery is immanent. However, especially for a first baby, this is unlikely.

An experienced doula can gauge your labor progress better than you can (unless you are an experienced mother). That’s not to say she knows your labor better than you do, but she has seen and heard other women in labor. She knows what active labor sounds like and looks like. It’s quite distinctive. There are some women who do not fit the usual pattern, certainly. But in my experience as a doula this is rare. Active labor sounds surprisingly similar for most women! I know midwives who can diagnose active labor quite accurately from listening to women during contractions on the phone. Having a doula help you decide when to go to the hospital helps you avoid getting to the hospital too early.

Why Going to the Hospital in Active (Not Early) Labor is a Good Idea:

Hospitals do not like to admit women before they have reached active labor. The hospital staff, and your doula, know that if you are in early labor you are more susceptible to having your labor slow down (sometimes slow WAY down!) if you change locations. Because we are mammals, our bodies are designed to slow or stop labor if we need to use our brains. Our bodies cannot tell the difference between having to use our brains to figure out how to escape a hungry lion and having to use our brains to answer the triage nurse’s questions. Either stimulation can cause our hormones to change and our labors to slow down or stop.

This is less likely to happen once we have made it to active labor (defined loosely as the cervix dilated to around 5 centimeters). Then, hungry lion or not, our baby is probably going to come pretty soon.

It is especially important to arrive at the hospital in active labor if you are planning a natural hospital birth. The later you arrive, the less time there is for interventions! If your labor is progressing at a leisurely pace, you do not have to worry about beating a clock or losing a favorite nurse at a shift change when you are at home.

Your doula helps you decide when it is the right time for you to get to the hospital. She knows what kind of birth you are planning and she can help you optimize your chances of achieving the birth you want.

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A: whoever will give the laboring mother a sense of calm and expectation. She thinks about being in active labor in the presence of a particular person (her mother, her best friend, her sister, her father-in-law, etc). When she imagines that person with her in labor she smiles. She knows that she will feel more energized, more secure if this person is with her. Invite this person!

Conversely, if a pregnant woman thinks about being in active labor around a person and finds herself wondering what that person will think or how that person will behave, if she frowns even just slightly while she imagines this person there, this is not a person to invite.

This process changes from birth to birth. The right birth team for your first labor is probably different from the right birth team for your third labor. We change. We grow. We need new kinds of support.

Anyone who wishes they could be with you in labor but who is not invited should have a special job to do during labor. Some of my favorite assignments for such people (grandparents, often):

1. Bake a birthday cake for the baby

2. Purchase the day’s newspaper and a lottery ticket

3. Have dinner ready for the family when they arrive home

4. Send them to the store for some absolutely necessary supplies: more diapers, more wipes, more baby blankets, whatever you can imagine needing. Just make it sound IMPORTANT!

5. Serve as the conduit for information to the rest of the world during labor. The dad or doula can make one phone call or send one text to this person who can then broadcast any information to the world that the birthing family desires.

6. Write a letter to the new baby on its birth day to welcome her or him to the world!

Why do I believe that a woman’s intuitive knowledge of who will support her best is the way to decide? I have a simple answer. A woman’s body is designed to shut down labor if she perceives even the smallest threat to herself. It doesn’t matter how much you love your mother or your friend. If you feel judged by this person in any way, you can compromise your labor. It’s not worth it. Be selfish! Consult your inner wise self and no one else.

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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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