May 28, 1999
Volume 1, Issue 22
Midwifery Today E-News
“Doulas”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Effects of Doula Care
5) The Comfort of Touch
6) Doula Service Featured
7) A Doula's Story
8) Switchboard
9) Coming E-News Themes

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1) Quote of the Week:

"One sees great things from the valley, only small things from the peak."

- Chesterton

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2) The Art of Midwifery

A technique learned at a Midwifery Today conference has dramatically affected my clients' birth experiences. It is more a philosophy than a technique. Valerie El Halta tells many of her classes, "I'm a lazy midwife.
I want to be there as early as possible in labor because it goes faster that way." Counter-intuitive as that may seem, it made perfect sense when I thought about it. I began telling clients to call me very early in labor rather than wait for active labor as many had been doing. Why? When they've been dealing with early labor on their own they've often been spending a lot of time worrying and getting scared, thus feeling more pain than necessary early on. Not only is that early part of labor less productive, but it's also longer when a woman spends that time getting more and more tense.

So I tell them to call me when it first starts to get uncomfortable, even if the contractions are only 20 minutes apart. I go, help them settle down and quit focusing on the contractions. I often send them to bed (at night) or have them eat a snack if they've stopped eating. I might show them a few techniques dad can use to help mom with the contractions as they curl up together in bed or snuggled up on the couch. Then I leave them alone if it seems appropriate and tell them I'm going to take a nap in another room.
This way they still have their privacy but also have the security of knowing someone is close. It really removes the fear--and since I work with women who birth in the hospital there's usually a lot of fear in the first part of labor.

- Jennifer Rosenberg, doula

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3) News Flashes

A recent study contrasted the influence of intermittent and continuous support provided by doulas during labor and delivery on five childbirth outcomes. Data were aggregated across 11 clinical trials by means of meta-analytic techniques. Continuous support, when compared with no doula support, was significantly associated with shorter labors (weighted mean difference -1.64 hours, 95% confidence interval -2.3 to -.96) and decreased need for the use of any analgesia (odds ratio .64, 95% confidence interval .49 to .85), oxytocin (odds ratio .29, 95% confidence interval .20 to .40), forceps (odds ratio .43, 95% confidence interval .28 to .65), and cesarean sections (odds ratio .49, 95% confidence interval .37 to .65). Intermittent support was not significantly associated with any of the outcomes. Odds ratios differed between the two groups of studies for each outcome.

Continuous support appears to have a greater beneficial impact on the five outcomes than intermittent support. Future clinical trials, however, will need to control for possible confounding influences. Implications for labor management are discussed.

- Am J Obstet Gynecol, 1999; 180: 1054-9; Kathryn D. Scott, Gale Berkowitz and Marshall Klaus, authors. Abstract submitted by Linda Greengas.

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4) Effects of Doula Care

Doula: A woman trained and experienced in childbirth who provides continuous physical, emotional, and informational support to a woman during labor, birth and the immediate postpartum period. Postpartum doulas care for new families in the first weeks after birth providing household help, advice with newborn care and feeding, and emotional support.

Effects on birth outcomes: Eleven studies showed the following effects of doula support: shorter labors, fewer complications, reduced cesarean rates, less need for oxytocin to speed up labor, reduced use of forceps, fewer requests for pain medication and epidurals.

Effects on the mother: greater satisfaction with childbirth, more positive assessments of their babies, less postpartum depression

Effects on the baby: shorter hospital stays and fewer admissions to special care nurseries, babies breastfeed more easily, mothers are more affectionate with their babies postpartum

Effects on the healthcare system: dramatically reduced cost of obstetrical care, women are pleased with the personalized care doulas offer

Given the clear benefits and no known risks associated with intrapartum support, every effort should be made to ensure that all labouring women receive support, not only from those close to them but also from specially trained caregivers. This support should include continuous presence, the provision of hands-on comfort, and encouragement.

- Hodnett, E. D. "Support from caregivers during childbirth." (Cochrane Review) in Cochrane Library, Issue 2. Oxford Update Software, 1998. Updated quarterly.

Facing unprecedented pressures to reduce expenses, many hospitals are targeting the largest single budget item--labor costs.... [An] unintended consequence of nursing cutbacks may be an increased cesarean rate; the inability of pared down nursing staff to provide continuous coverage to laboring mothers [has been] shown to increase the chance of cesarean....

Doulas clearly improve clinical and service quality; they provide an absolutely safe way to reduce cesareans and other invasive birthing interventions.

- Coming to Term: Innovations in Safely Reducing Cesarean Rates. Medical Leadership Council, Washington DC. 1996.

The continuous availability of a caregiver to provide psychological support and comfort should be a key component of all intrapartum care programs which should be designed for the effective prevention and treatment of dystocia (non-progressive labor). Guidelines on Dystocia. Society of Obstetricians and Gynaecologists of Canada, 1995.

(information provided by Nicette Jukelevics, DONA Public Relations Committee Chair. To find out more about DONA, visit their web page at http://www.dona.com, email at ASKDONA@aol.com or call 206-324-5440.)

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5) The Comfort of Touch

As a massage therapist who specializes in pregnancy I am very comfortable with touch, so it is natural for me to have a lot of physical contact with women during their labors. At the last birth I attended I fully realized the huge difference I was making by simply touching the mother's body.

I was with a woman who was trying to have a "natural" hospital birth. She had strong feelings about not wanting an epidural. Her labor stalled at 4 cm and her doctor insisted upon Pitocin to "get things going." When her blood pressure started to rise the doctor required her to stay in the bed and not move around. Feeling there was little for me to do, I sat next to her bed and made one long, continuous, flowing movement with my hand. I started at her temple, moved down her neck, shoulder, arm, hip, leg and ended at her foot. I repeated this stroking for about 30 minutes. When I stopped for a break the woman said "I need to feel you touching me until the baby is born." I agreed, and didn't break skin to skin contact for the next two and a half hours. We spoke after the birth and she said that as long as she felt the warmth of my hand she knew she could handle the pain and that everything would be all right.

If we doulas, nurses and midwives can remember the importance of something as simple as touch, I think we could provide a great service for our clients.

- Keri Redding (I would love to share my thoughts with anyone interested in birth doulas. My email address is mikeandkeri@earthlink.net)

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6) Doula Service Featured

As a labor support and postpartum doula for thirteen years, I have enjoyed the support, encouragement and partnership of many midwives. When doulas and midwives work together we can create a circle of nurturing for all involved. I have been fortunate to work in the training and development of several community based collaborative doula programs. The most recent was the Midwifery Practice and Doula Service at the State University of New York at Stony Brook, chosen to be featured in an upcoming national documentary called "Indivisible" which celebrates diverse efforts to build and sustain strong communities across America. This project is supported by The Pew Charitable Trusts and is based at the Center for Documentary Studies at Duke University, with The Center for Creative Photography at the University of Arizona.

"The examples portrayed by Indivisible will illustrate the various challenges people face in their communities and the progress they can make when they work together. Through a collective portrait, Indivisible will encourage Americans to talk about new ways to share ideas and resources to make their own communities better places to live." (Indivisible brochure 1999)

I hope you share with us the honor and challenge I feel in having midwives and doulas chosen as one of 12 sites to be featured for release in mid-2000.

I would love to hear from other midwife and doula programs as we create broader models of care for our families and communities. Debra Pascali-Bonaro CD(DONA), CBE Motherlove@cwix.com

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Learn more from these Midwifery Today issues:
No. 19, Trends vs. Tradition (Regular price $7.00)
No. 44, Trusting Birth (Regular price: $10.00)
No. 47, Normal Birth (Regular price $10.00)
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7) A Doula's Story

It was obvious that Winnie's labor was going to be long, even though this was her second pregnancy. I remained at her home all day, making sure she took it easy, rested, ate, drank plentifully to stay well hydrated and avoid an IV once she was in the hospital. I massaged her feet and back with lavender oil, reminded her what her body was doing, encouraged her to stay relaxed and loose, and asked her to rest. By evening we took a walk to stimulate labor, which only worked for awhile. Later she took a bath, got some sleep and I went home to get some rest too.

The next day, after she had been in active labor for awhile, we went to the hospital labor and delivery area. Winnie's contractions were 3-5 minutes apart, she was dilated to 5 cm, 90 percent effaced and baby at zero station. As her doula, I was so proud of her progress, and she was amazed.

She was still considering an epidural, but her doctor said she was so far dilated that she might just get this labor over with quickly. I encouraged her to wait, reminding her of her wish to labor naturally, and she began to think she could really do it.

Within the next hour Winnie was at 7 cm and her doctor told her it was decision time: she could get the epidural, but it wasn't recommended (great doc!). Winnie decided she didn't want to give up her freedom of movement, so she opted against it. At this moment I knew she was going to get the best birthing experience she wanted.

Winnie chose to stay out of bed. She mostly stood by the side of the bed, and during each contraction she squatted, got on all fours, or leaned over a birth ball. The nurses and doctors stood around watching while I rubbed her back, did counter-pressure, talked soothingly and was one hundred percent there for her. The hospital got a good look at a normal labor!

At 9 cm Winnie had wonderful urges to push. I suggested she go with them but not hold her breath and push on top of them. What amazed me was how she was still standing, even though she was in transition! When she reached 10 cm it took only two pushes to get her daughter into the world.

Because there had been no interventions other than fetal monitoring, Winnie was up within the hour and moved to postpartum right away. She was up and about later that day, thrilled with her birth experience. She was grateful for my support in staying with her throughout the long labor, and was convinced if she had been alone she would have been tempted to go to the hospital early.

I'm certain that the best a doula can offer is her trust in the labor process and her unwavering support. This calms the mom and other family members. I now truly believe most of labor should happen at home where mom is comfortable with her own pace and where Mother Nature can do her best work.

Sue Coffman is a certified doula who lives in Orange, California.

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8) Switchboard

I am a doula and the convenor of a support group called Birthrites: Healing After Caesarean. We support women who have previously had a c-section in their future birth choices (pro-VBAC), though we are also endeavouring to support women in future c-sections (where necessary) to make the surgery more acceptable to both mother and child.

Not all women are upset at having had a c-section, and these women don't need our help at the moment. But the women who do approach us tend to choose the complete opposite of their last "technological" birth experience. After being informed of their choices and the safety of VBAC (depending on the reason for their last c-section), they find empowerment within themselves and make informed decisions that enable 80 percent of them to experience "natural" birth the next time. These women tend to avoid drugs, epidurals, usually even hospitals if they can, choosing homebirth midwifes to support them, thereby increasing the percentages even more. I am so glad we have midwives here in Western Australia who support us in this way.

Please inform women of our program so we can continue to support them and try to make a difference in the way that at least some babies are born worldwide. I truly thank God for caesareans when they are necessary. It is the unnecessary ones that our group are trying to reduce--the emotional repercussions, as well as the physical ones, experienced by both mother and child are too high.

- Jackie Mawson. Convenor of Birthrites: Healing After Caesarean Inc. phone: 61 08 9418 8949; e-mail: cmawson@nd.edu.au website:
http://edsitewa.iinet.net.au/birthrites/

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Using castor oil for inducing labour seems to be an accepted practice in the U.S., whereas here in Australia and also in the UK where I trained it is used much more conservatively.

I am a homebirth midwife who tries to make my practice as research-based as possible without compromising my intuitive skills and sensitivity to individual women and their families. I have not come across any research that proves that castor oil is safe and non-toxic, and effective. I have seen it work and I have heard lots of stories of it working but have never found any substantial data on random-controlled trials or the like.

Consequently I do not suggest this to my clients. Also, one of my clients used castor oil a few years ago, had hypertonic contractions and had an amniotic fluid embolism. She and her baby both died. I was devastated, but even more so when I read a research article that related a similar story and warned against the use of castor oil and the risk of hypertonic contractions.

I have not managed to find any specific information on castor oil and any effect it may have on the gut wall, whether some of it can be absorbed and be toxic, etc. It is a traditional midwives' remedy, but of course that doesn't necessarily make it safe. I would like to know if the midwives who use castor oil base this practice on any sound information other than anecdotal evidence. I would like to use it more if only I were sure it is safe and give my clients some idea of the probability of it working.

- Marianne Idle, registered midwife

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I am an aspiring midwife, trained doula, and mother of a homebirthed daughter. I really want to become a midwife, but I am unwilling to give up my dedication to attachment parenting, and I cannot figure out how to incorporate midwifery school with a toddler. Has anyone else juggled these two things successfully?

- Kelli Lincoln

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I had many, many responses from my "thoughts" which were printed in E-News a few weeks ago. I now correspond with over a dozen women all over the U.S.! We are all very interested in anything that can educate us further in making pregnancy and birth the absolute best it can be!

- Tina Z.

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Midwifery Today E-News is not staffed to handle requests from people who are trying to find a midwife. However, Online Birth Center News, a free birth activist newsletter, has a Looking for Midwife section. Send your request to djz@efn.org, with OBCNEWS ITEM in the subject. If you'd like to subscribe to the OBCNEWS, write to the same address and ask to be added to the subscription list.

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9) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- doulas (May 28)
- induction (June 4)
- educating the public (June 11)
- episiotomy (June 18)
- Group B Strep (July 9)
- homebirth (July 16)
- epidurals
- breastfeeding
- waterbirth
- breech birth
- nutrition

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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