Midwife & Lactation Consultant
Need more evidence and reasons to hire a doula? Or want to explain to someone else why you are hiring a doula, or why they might want to consider hiring a doula? Watch this video from Evidence Based Birth for a rundown on what we do and how we can help birthing families.
Watch the video from Evidence Based Birth here.
Happy World Doula Week to all the doulas out there!
POSTBIRTH - An Acronym that Can Reduce Maternal Mortality and Morbidity in the Postpartum Period
by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
Full text of the article can be found here.
Maternal mortality and morbidity in the United States are as high as they have ever been. More people are dying from complications of pregnancy or childbirth than ever before. 61 percent of deaths related to childbirth occur in the postpartum period and most of those occur in the first 42 days after birth. The current estimated maternal mortality rate in the U.S. is 23.7/100,000 live births (MacDorman, Declercq, Cabral, & Morton, 2016).
There is agreement that we must improve the way we care for people in the postpartum period if we want to be able to reduce the complications and deaths that occur after giving birth. Part of this improvement lies in how warning signs information is provided to families after birth. As it is not possible to identify who will have a postbirth complication, it is imperative that everyone receive information about concerns in the postpartum period that will need to be evaluated by a health care provider. The postpartum nurse or mother-baby nurse is in a unique position to educate families on what to watch for postpartum.
Unfortunately, current research indicates that the information that postpartum nurses teach to new parents about warning signs is inconsistent and often inaccurate. There is also evidence that many postpartum nurses are not aware of the major risks that face people after they give birth that can cause death or serious complications. Families report being flooded with physical and emotional situations in the first days postpartum that make it difficult to take in important information accurately and clearly. For these reasons, the postpartum discharge education RNs provide must be clear, concise, and accurate. When appropriately informed and educated, postpartum nurses are in an ideal position to improve postbirth outcomes, if they are given adequate time to share information with the new family.
A new study, Nursesʼ Knowledge and Teaching of Possible Postpartum Complications, published in MCN: The American Journal of Maternal/Child Nursing, examines postpartum nurses’ knowledge of maternal morbidity and mortality, and information they shared with women before discharge about identifying potential warning signs of postpartum complications.
Almost half the postpartum nurses in the study were not aware that maternal mortality rates have increased. Almost all (93%) of nurses knew that hemorrhage was one of the top three causes of death, but only 68% knew that hypertension was another, and barely 39% could identify infection as the third leading cause of death.
The following text and photo is excerpted from "Evidence on: Doulas" a recent article August 14, 2017 by Rebecca Dekker, on her incredibly informative website, Evidence Based Birth. You can read the full text of her article here: https://evidencebasedbirth.com/the-evidence-for-doulas/
There are several reasons why we think doulas are so effective. The first reason is the “harsh environment” theory. In most developed countries, ever since birth moved out of the home and into the hospital, laboring people are frequently submitted to institutional routines, high intervention rates, staff who are strangers, lack of privacy, bright lighting, and needles.
Most of us would have a hard time dealing with these conditions when we’re feeling our best. But people in labor have to deal with these harsh conditions when they are in a very vulnerable state. These harsh conditions may slow down a person’s labor and their self-confidence. It is thought that a doula “buffers” this harsh environment by providing continuous support and companionship which promotes the mother’s self-esteem (Hofmeyr, Nikodem et al. 1991).
A second reason that doulas are effective is because doulas are a form of pain relief in themselves (Hofmeyr, 1991). With continuous support, laboring people are less likely to request epidurals or pain medication. It is thought that there is fewer use of medications because birthing people feel less pain when a doula is present. An additional benefit to the avoidance of epidural anesthesia is that women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring (Caton, Corry et al. 2002).
This finding—that people with doulas are less likely to have an epidural—is not due to the fact that clients with doulas in these studies were more likely to want these things up front and were more motivated to achieve them. In fact, randomized trials account for these differences—this is why they are called randomized, controlled trials. The people assigned to have a doula, and those assigned to not have a doula, are randomly assigned, meaning that the same percentage in each group would have a desire for an unmedicated birth.
A third reason why doulas are effective has to do with the attachment between the birthing person and doula which can lead to an increase in oxytocin, the hormone that promotes labor contractions. This theory was proposed by Dr. Amy Gilliland in her 2010a study about effective labor support. In personal correspondence with Dr. Gilliland, she wrote, “I believe the Doula Effect is related to attachment. When the mother feels vulnerable in labor, she directs attachment behaviors to suitable figures around her, who may or may not be her attachment figures (parent, mate). When the mother directs attachment seeking behaviors to the doula, the experienced doula (25 births or more) responds in a unique manner. She is able to respond as a secure base, thereby soothing the mother’s attachment system. The accompanying diminishment in stress hormones allows for a surge in oxytocin in both the mother and the doula… theoretically, oxytocin is the hormone of attachment, and it is released during soothing touch and extended eye contact, which are habitual behaviors of birth doulas.” (Personal communication, Dr. Amy Gilliland, July 2015).
Swedish oxytocin researcher Kristin Uvnas Moberg writes that the doula enhances oxytocin release which decreases stress reactions, fear, and anxiety, and increases contraction strength and effectiveness. In addition, the calming effect of the doula’s presence increases the mother’s own natural pain coping hormones (beta-endorphins), making labor feel less painful (Uvnas Moberg, 2014).
Based on the evidence, I have come up with a conceptual model of how doula support influences outcomes.
A conceptual model is what researchers use to try and understand how a phenomenon works. Here is my conceptual model on the phenomenon of doula support.
These photos are beautiful! Whether it's a home birth, hospital birth, natural birth, cesarean birth, midwife birth, water birth, OB birth, breastfeeding or formula feeding, or it's a first or second or third child... there's no one right way to do it. Take a look here.
Science and Sensibility, the research blog from Lamaze, has an excellently evidence based article on the practice of delayed cord clamping. The article is structured by listing objections, which is a great way to go about learning the benefits, as well as to be prepared to answer to someone's concerns about this practice. Delayed cord clamping is becoming so much better understood and common place. Many Ob and midwife practices in Brooklyn and NYC do this as a matter of protocol.
Read the full article here.
I adore this blog post written by my dear doula colleague, Yiska Obadia. You can read an excerpt below, and the full article here.
"Doulas are there to serve their clients. You want to birth naturally? I will support you. You want an epidural? I will support you. You want an epidural and to avoid a c-section? I will do my best to help you achieve that. Doulas serve our clients in helping them to achieve the birth THEY want as well as supporting them wholeheartedly with the birth they get."
This article is definitely worth a read if you are pregnant and preparing for labor. And especially if you are interested in anatomy! According to the article, it may be particularly applicable if any of the following are present:
A long and difficult labor in which normal remedies (Rebozo Sifting, Position Changes, Spinning Babies Maneuvers) are not fully effective
Persistently malpositioned baby
Highly athletic mother (especially those who are highly athletic into their pregnancy)
History of any trauma in which the ligaments of the pelvis could have been affected (accidents, falls, etc.)
A visible Pelvic Upslip: One (usually left) iliac crest superior to the other, one leg (usually left) functionally shorter than the other.
http://spinningbabies.blogspot.com/2016/04/the-sacrotuberous-ligament-key-to.html?m=1
As a birth doula serving clients who live primarily in Brooklyn and Manhattan, I work with many women who see both OBs (often low intervention practices) and midwives in the hospital setting. However, many of my clients are looking for a holistic birth experience, or a natural birth experience, within a setting that typically is not set up to accommodate un-medicated births. The odds are generally stacked against women hoping to have intervention-free births in a hospital. BUT, as a doula, I have witnessed many women successfully do this! Here are a few resources on how to work towards, or achieve some version of, a natural hospital birth:
I have not yet met a woman who does not want to avoid an episiotomy in birth!! Read on below to get some tips on how to avoid this unwanted procedure, published by Choices in Childbirth.
Childbirth, Midwifery, Nutrition, Pregnancy, Sexuality
“How can I avoid an episiotomy during birth?”
Today an episiotomy is no longer a routine procedure – thank goodness – but is performed for cause. Some reasons include a tight perineum which prevents the baby’s head from distending the perineum, prior scarring of the perineum, female circumcision, and/or the baby’s heart beat is low and delivery needs to be expedited. We can decrease the problems with the perineum but not some of the other causes.
The other question is how to prevent natural tears of the vagina and the perineum. It is important for women to know that there is a group of muscles in the vagina that support the vagina, bladder and rectum. These muscles need to be strengthened and toned prenatally to increase their elasticity to allow for relaxation of the vagina and perineum during birth. These same muscles need continued exercise for the remainder of our lives. Thank Dr. Kegel for giving us the Kegel exercise!!
Proper overall fitness is important so consider walking and squats for toning. Proper nutrition is also key. Make sure that you get adequate protein and other nutrients for your tissues to respond well to the stretching of birth.
Keeping the vagina healthy and reporting any signs of an infection to your provider promptly to maintain good vaginal tissue integrity is hugely important. Perineal massage is advocated by many to be helpful in preparing the vagina and the vaginal muscles for birth. This needs to be initiated at 34 weeks and done for approximately 5 minutes 3-4 times per week.
When it comes time to push, your position is important, as is the use of warm compresses on the perineum. The lateral position or squatting for birth is protective of the perineum.
Finally, a slow, controlled delivery of your baby’s head will definitely help to decrease tears. This is difficult when you have a very strong urge to push. I recommend practicing techniques learned in childbirth classes such as focused relaxation.
Susan Papera, CNM,MSN received her undergraduate degree from Cornell University and her Master’s degree and Midwifery from Columbia University. She joined the staff at NYC Health + Hospitals/North Central Bronx as a staff midwife shortly after the Obstetrical services were open in 1978 and she has been helping to care for the women and families in the Norwood section of the Bronx ever since. Presently, she is Director of Midwifery Services. Working with such a richly diverse group of women is extremely rewarding and also an on going learning process as she says. Ms Papera is particularly proud of the fact that she is an NCB “Grandmother”- babies she has helped into the world are returning and she has had the privilege of helping their babies into the world.
You've chosen your doctor or your midwife; you've decided on the hospital, the birthing center, or giving birth at home; you've decided on a natural birth or that you'll use pain medication or maybe something in between; you have a list of baby names; you have the baby gear list... so what's missing? Your doula, of course! For some couples, whether or not to hire a doula is not an easy choice. One of the main concerns I hear from couples - especially those who are planning to have a natural birth with full support of their partner - is that they wonder if a doula is really necessary. Completely valid question. Below is an article that gives you some perspective on the Doula and the Dad - although prefer to use the term " birth partner" as there's not always a dad in every birthing couple!
Excerpt:
"But doulas aren't there only for moms-to-be. They also play a key role in helping their partners, offering them invaluable emotional and practical support during the overwhelming experience of childbirth. "I see myself as having many roles, fitting in where I am needed, lifting up and supporting the partner in order for them to support the laboring mom," says Zoe Etkin, a birth and postpartum doula and women's sexual health coach in Los Angeles. "Looking back on the birth, I hope they will both remember how connected they were, and I will just fade into the background. Although I believe my role is important, it's ultimately about the birthing couple."
Even so, it's common for dads-to-be to worry that having a doula during delivery might push them out of the main labor support role. Doulas insist that couldn't be further from the truth. "I'm there to accentuate their involvement, not to take their place," explains Gena Kirby, a doula of 10 years, childbirth educator, and host of Progressive Parenting radio. "Partners have taught me so much over the years about different ways to approach different personalities and births."
Full article here.
These 6 principals by Lamaze are great way to set yourself up for a healthy birth. Take a look at this quick and easy-to-understand video below.
Recently, on my Facebook feed, there have been a bunch of articles circulating about doulas. Most of them accurately describe the general benefits and the research that proves we are a positive influence on a woman's birth experience and outcome. But then the articles often take funny twists and spiral down an odd road, describing the downsides of a doula, or scenarios which completely misrepresent the doula industry. (Most commonly the bring up doulas who don't support epidurals. I know a lot of doulas in NYC, and every single one of them, including me, supports a mother's choice to use an epidural in labor.) What if all articles about OGYNs or midwives or dentists, or geez, babysitters did the same thing and focused on a misperception that is uncommon in their industry? In any case, here's an article, for once, that doesn't seem to do that. Hurray!
Read the lovely article here: Doulas, What They Do and Don't Do, by Amelia Pang. Excerpt below.
"A doula is a non-medical professional who is certified to give physical comfort and emotional support to a woman before, during, and after delivery. Doulas can provide essential information about birth, and are on call 24-hours a day.
Although studies show doulas can greatly improve birth outcomes, not many women in the United States hire doulas.
According to the Second National U.S. Survey of Women’s Childbearing Experiences taken in 2006, only 3 percent of women said they used a doula during childbirth.
This is partly because there are some misconceptions about what doulas are and what kinds of services they provide."
To read the full report on insurance coverage of doula care, click here. Thank you to Choices in Childbirth and Childbirth Connection for putting this long overdue information together. Here's the intro:
"Doula support is a proven strategy to improve the quality of maternity care – leading to better health outcomes and a more satisfying experience of care. But too many women still cannot afford doula support, despite its proven benefits.
Choices in Childbirth and Childbirth Connection, a program of the National Partnership for Women & Families, have been working together on a joint issue brief, “Overdue: Medicaid and Private Insurance Coverage of Doula Care.” The brief documents how widespread access to doula support would improve outcomes for women and babies, enhance women’s experience of care, and reduce the cost of care. Doula support is a high-value form of care that warrants widespread Medicaid and private insurance coverage and the brief identifies a variety of strategies to achieve this. These range from pregnant women and advocates making the case to individual insurance plans, to new pathways to obtain Medicaid coverage of doulas as non-licensed practitioners, to designation as a recommended preventive service by the U.S. Preventive Services Task Force, and asking Congress to act to ensure that doula care is a universally covered service under Medicaid."
http://choicesinchildbirth.org/our-work/advocacy-policy/doulacoverage/
"The presence of a doula at birth was linked to an almost 60 percent reduction in women's odds of having a C-section, and 80 percent lower odds of having a nonmedically indicated C-section compared with women who had no doula. (Overall, 10 percent of the women in the survey said they had no clear medical need for a cesarean delivery, yet delivered via C-section anyway.)
Women with doulas also had significantly lower odds of having a C-section -- both for clear medical reasons and otherwise -- than those who wanted a doula but did not have one.
"What our study showed is that [lower odds of a C-section] don't come with wanting a doula; it's having a doula that is actually associated with important and substantial risk reductions," Kozhimannil said."
Read the full text of the article here.
http://www.huffingtonpost.com/2014/08/29/doula-benefits_n_5730720.html