To Doula or Not to Doula

Week 32

Hubby and I have been on and off the doula train since we found out I was preggers. For those not in the know, a doula is a birth attendant/ labour coach separate from a mother's medical caregiver. A doula offers emotional and physical support to a woman and her partner before, during and after childbirth. DONA (Doulas of North America) explains it like this:

“Women have complex needs during childbirth. In addition to the safety of modern obstetrical care, and the love and companionship provided by their partners, women need consistent, continuous reassurance, comfort, encouragement and respect. They need individualized care based on their circumstances and preferences. The role of the birth doula encompasses the non-clinical aspects of care during childbirth.”

Doula support generally includes:

• Birth education and preparation
• Birth planning (including creating a written birth plan/birth preferences document)
• De-briefing previous births
• Massage and other comfort measures
• Optimal fetal positioning
• Suggesting positions and changes to help ease pain and facilitate a smoother, more effective labour
• Providing reassurance and encouragement
• Talking through emotional blockages which may come up in labour
• Maintaining Ambiance – aromatherapy, music, candles etc
• Assisting with negotiating with medical staff if what the mother and the hospital wants differs
• Photography and/or vide0

The etymology of the word, awkwardly enough, originates from the Greek term δούλη meaning 'female slave'. It was first used in a 1969 anthropological study documenting birthing traditions around the word. Historically, in most societies a cadre of women supported mothers through labor and birth. This was a role usually occupied by female family members or friends. Over time, as our birthing process (in North America at least) became more institutionalized and less community focused, our networks of women with significant birthing experience dwindled to the point where if we want skilled help now, we have to pay for it.

Part of me thinks that's kind of fucked up.

I mean, what happened? Did life get so busy that we forgot how to give birth? Why would I spend $800 - $1200 dollars hiring someone to speak up for me, rub my back, and give my husband a break when I'm off my tits on adrenalin during transition? Isn't that what family and friends are for? Surely we can light our own candles, create our own 'unique' experience, and not have to pay somebody to do it for us.

Theoretically, yes. My husband, family and friends are more than capable of doing all these things and more. However, labour can be-- and most often is-- an intense and personal experience, especially if we don't know what the hell's going on, which most women (especially with their first babies) don't.

Add to that the fact that the average labour lasts eight hours, and that a doula is there for support the entire time. Is it fair to expect my family and friends will reliably do the same, at any time of day or night, with little or no birthing experience, busy jobs, and busy lives? Will they happily rub my feet as I projectile vomit across the room during contractions?

To be honest, as much as my friends and family are happy to help (thanks guys!) I'd feel bad puking on their shoes, and I'd personally feel more at peace having someone else around with specialized birth experience to normalize the whole intimidating process both for me and my husband.

There is also a growing body of evidence that confirms concrete medical benefits to doula care. Studies (and reviews of the studies) demonstrate that working with a doula through birth and labour ends in significantly fewer caesarean sections, fewer incidences of forceps and/or vacuum assisted births, and fewer stitches in one's vagina (hurrah!), in addition to higher self-esteem and less anxiety and depression for the mother at 6 weeks post-partum. These benefits are significant enough for me to believe that a doula would be a worthy investment.

The bottom line is that I know my husband and I could survive the birth of our baby, but this isn't a process I simply want to 'survive'. It's an experience I want to enjoy and cherish as much as humanly possible.

We met with a doula yesterday who has a plethora of experience as a labour coach. She lived in Kathmandu Nepal for fifteen years and gave birth to her two sons in a small clinic there, where she also volunteered her labour services to friends and family. She has deep, beautiful smile lines and laughed freely with us about the fact that my cat attacked the last doula we interviewed, who neither my husband nor I connected with so much. She has experience in everything from emergency caesarians, to water births, to home births, to straight up old-fashioned hospital labour. She was very clear that her role in no way takes away from the father's role, or any other friends/ family that attend. Rather, as someone experienced in the ups and downs of childbirth, she can guide and reassure when needed - especially during the most intense times - so everyone can simply be present and make the most of the experience.

I liked her a lot, and would be happy to pay her very reasonable fee which includes pre and postpartum in-person visits, unlimited phone and email consultation, and in-person care through my entire labour.

She also works for this amazing program in Vancouver: 

http://scbp.ca/ 

The South Community Birth Program (SCBP) was established in 2003 to pilot a unique maternity care system in the under serviced South Community area of Vancouver. Family physicians, midwives, community health nurses, and doulas work together cooperatively (all covered by MSP!) in a community-based, culturally-appropriate, and woman-centered manner during pregnancy, birth and the newborn period.

It's the first 'shared care' program of its kind in Canada, and I hope it catches on. I've saved my pennies and am lucky enough to be able to afford a doula this time around, but I'd argue that most women can't. Should women suffer limited care and an increased risk of serious intervention during childbirth because they can't afford a doula?

I think not. Bring on the doulas I say.

Assume the Position

30 Weeks

I suck at meditating. It's the hardest thing in the world for me. I'd rather run a marathon in a shitstorm than sit for any length of time without moving. It's taken a lot of research, patience, and perseverance to cultivate a regular meditation practice over the years and I still suck at it. 

I always thought it was my mind that was the problem. My brain is like the fucking Swamp of Sadness. My thoughts wander into a bottomless sandpit of doom and literally suck me into oblivion. I’ve battled depression since the ripe old age of fifteen, at times seriously enough to be medicated. Physically moving around, running or practicing yoga asana for example, can help to calm me down. Sitting still with no distractions often makes things worse.  

My dear friend Craig, who I've written about before, was a practicing Buddhist and Zen meditation teacher. He gave me this book and clued me into the fact that it wasn't my brain that was the issue. We often think of meditation (and depression for that matter) as an activity involving our minds, but in truth meditation, and I believe depression to some extent, is initiated by assuming a specific gesture with our bodies. If any one element is out of whack, it's practically impossible for the mind to achieve stillness and clarity. 

What we need to do- first and foremost- is turn our bodies into a cathedral and create space for our minds to follow. Instead of carved stone, the building blocks of the human body are the feet, lower legs, upper legs, the pelvis, the abdomen and lower back, the chest and upper back, the shoulders and arms, and finally the head. If these segments can be stacked on top of one another, the body will be able to sit (or stand) in an elegant and balanced way.

Like so:

A balanced posture requires very little energy to sustain and also allows the body’s major muscles to relax. Subsequently it’s much easier for the mind to relax as well.

I remember the first time this 'clicked' for me. Craig sat me down on his meditation pillow and added additional support under my knees. He adjusted my chin (apparently I have writers neck from leering forward at a computer screen all day) and also tucked in my lower ribs. Once I relaxed into this gesture, I felt like I'd just popped an Ativan: a quiet, dull calm settled into my bones. My body sighed and my mind (finally!) let go. 

That feeling of mental and physical ease lasted all of thirty seconds, but since then it's been easier to 'click' into that space where my whole being can mindfully rest, if only for a short amount of time. 

So here's what I'm thinking… 

If posture can have such a significant affect on our body and mind's ability to relax, why not apply the same principles to childbirth? Surely squeezing something the size of a small watermelon out of my vagina could be made slightly more bearable by assuming the optimal position, no?

Unfortunately mainstream medicine doesn't feel the same way.

More than half of women who gave birth vaginally in hospital in Canada reported that they lay on their backs in labour. Slightly more than one-third indicated they gave birth in a propped up (semi-sitting) position. Is it any wonder that interventions such as episiotomies, forceps and suction births are so much more likely in hospitals?

There are a number of reasons why lying on your back with one's feet in stirrups is not even remotely helpful in opening the hips and pelvis. 

First of all, stirrups are for cowboys. 

Secondly, lying on your back actually decreases the size of the pelvic outlet; it forces the woman to put direct pressure on her sacrum (tailbone) which flexes it upward, forcing it into a curved position which can inhibit the baby's descent. The birth canal is effectively placed in an "uphill" orientation, forcing the mother to push upward against gravity to expel the baby. 

Thirdly, what about gravity? Sitting or standing upright makes sense because of the simple fact that the weight of the baby will naturally pull it down, in, and out of the pelvis.

Optimal birthing positions use a combination of gravity and physiology to relax the muscles, allow the mother's sacrum and coccyx the freedom to rotate backward and consequently create a perfectly stacked 'cathedral' for the baby to pass through.

*insert sounds of heralding angels here*

There are five main types of labor and birth positions that facilitate heavenly pelvic opening. While some are definitely not glamorous, they each offer unique benefits to mother and baby.

1.Quadruped childbirth positions (on hands and knees) are beneficial for back labor, turning a posterior baby, and are often the best birth positions for birthing a large baby.

2. Sitting positions combine the helpful force of gravity with relaxation. A birth ball, rocking, or toilet sitting can be utilized to rest while gravity helps labor progress. 

3.Squatting positions are helpful in opening the pelvis to allow a baby to find the optimal position for birth. Squatting can be performed through use of a birth companion or a tool such as a squatting bar.

 

 

4. Side-lying positions are beneficial for resting during a long labour, promoting body-wide relaxation, and minimizing extra muscular effort. They are best used in the latter stages of labor since gravity isn't able to speed the process.

5. Upright positions for childbirth use gravity to the mother's advantage. They help the baby drop into the pelvis and prevent pressure from being concentrated in a particular spot. They represent the most under-used birth positions. 

 

These positions have been documented historically in cultures around the world. So the lingering question for me is this: if studies confirm that a mother needs to explore her own optimal birthing positions based on her unique physiology and the position of the baby, why the hell are most of us still stuck on our backs with our feet in the air?

The story, true or not, is that Louis XVI wanted to see the birth of his son (something men were not permitted to do at the time, but he was King so he could do what the hell he wanted) and asked the obstetrician if he could place Marie Antoinette on her back with her legs extended to facilitate his wishes. 

The obstetrician realized that this position made things much easier for him - he didn't have to stoop down and look up at the woman, which was not only difficult physically but socially demeaning. So he continued to use this position for delivering babies, and other obstetricians picked up the practice quickly. 

I don't think there was actually a law concerning this, but I could be wrong. In any case, this position has continued to be favoured by obstetricians and used in many hospitals. Midwives continue to favour letting women assume whatever position works best for her.

I can only conclude then, for lack of other evidence, that laboring on one's back is mostly for the convenience of the doctors rather than for ease of passage for unborn child and mother. 

One could argue that maternal death rates have dropped since Louis and Mary Antoinette’s time (though they are actually on the rise in America) so we must be doing something right. I credit this to advancements in infection management and also surgical interventions when necessary, more than ‘advancement’ in birthing positions. 

Just because historic rates of maternal death were much higher in the past they are today does not mean we should not consider historical practices and birthing positions when thinking about labour. 

Our bodies are cathedrals, beautiful works of art. Let's not make this the status quo:

Additional Resources:

While writing this post I came across a book entitled Labor Among Primitive Peoples  by George Julius Engelmann MD that includes some amazing diagrams of traditional birthing positions. It is available in it’s entirety thanks to the power of Google Books! 

TheBusiness of Being Born

SpinningBabies