It is 3:20 am and the phone rings.  I am asleep in the guest room so this call, which I have been anticipating since dinner last night, will not wake my husband.  I am showered, dressed and in the car by 4:05 am.  When I arrive at work, the door is ajar.  I silently step inside, slide off my sneakers and make my way up to the bedroom.  There, standing by the side of the bed, is my client.  Her breath is rapid but soft.  She looks up at me with a quiet look of fear, now tempered with relief and hope.  I am a doula.  This is how my work day begins.

As a doula, I am constantly explaining what I “do”.  Rather than one stock answer I find I have different definitions that I dole out depending on who is asking.  My shortest answer goes like this, “I provide physical and emotional support for the mother before during and after her birth experience.”  The reality is so much more involved.

I am reminded today, on Mother’s Day, that being a doula means I have the privilege of watching women become mothers all the time.  But it also means my daughters have begrudgingly learned I have an unpredictable schedule.  I often tuck them into bed with a kiss and, “Mommy might have to go meet a new baby tonight.  If I am not here in the morning please be good for Daddy.”  This can place a huge toll on family life.  My husband may need to work from home.  After school activities become more complicated with one car.  Our RSVPs are tentative at best.  I am the doula, but my family is too.  I never take their sacrifices for granted.

My relationship with most of my clients begins months prior to their due date.  Perhaps they are taking my childbirth class, or a friend has referred them to me.  After a woman and her partner decide to hire me we both sign a contract.  A doula’s contract works as a retainer.  Once it is signed I am hers for any consultation she made need: phone calls after a stressful doctor’s appointment, emails asking how to relieve back ache, editing birth plans, reviewing breathing techniques, the list goes on.

As a baby’s birthday approaches the contacts are more frequent, even daily.  Some mothers need reassurance with every cramp.  Others just need to discuss logistics.  While each client receives an in-home prenatal appointment, my accessibility is limitless right up until the birth.  Which brings us back to our opening scene.  

I arrive at a clients house and I immediately work to help mom and her partner settle into the reality of labor.  Assurances are whispered, mom relaxes into a comfortable pattern, and we wait for the intensity to increase.  I will stay with a family until they are settled, anywhere from 2 to 4 hours after the birth of the baby.  This means I have spent any where from 5 - 48 hours with a couple as we wait for the baby to arrive.  There is never any way to know how long I will be “at work”.  

During those long hours, when days and nights flow together in a swirl of position changes, nourishment, massage, varied breathing patterns, showers, baths, and words of encouragement I wait and smile patiently.  Moms always want to know how much longer?  I always have to answer with, “I don’t know.  But I do know you are doing great.  You are strong and we are here for you each step of the way.”

I love my job.  I am a doula.

Why use a doula:

Clinical studies have found that hiring a doula:

• tends to result in shorter labors with fewer complications
  
• reduces negative feelings about one’s childbirth experience
• reduces the need for pitocin (a labor-inducing drug), forceps or vacuum extraction and cesareans
• reduces the mother’s request for pain medication and/or epidurals

Research shows parents who receive support can:

• Feel more secure and cared for
• Are more successful in adapting to new family dynamics
• Have greater success with breastfeeding
• Have greater self-confidence
• Have less postpartum depression
• Have lower incidence of abuse

Resources to find out more and hire a doula:
DONA International
Doula Match
MD State Representative for DONA

Pop quiz: What is the fastest way to warm a new born baby?

a) Place it under a $5,000 infant warming system
b) Swaddle it tightly in multiple blankets
c) Place is directly onto it's mother's chest

If you answered a) guess again.  I recently worked on an "evidence based project" with a team of RNs from a Baltimore hospital. Evidence based practice is finding a renewed following in hospitals.  What!?  Don't we use scientific evidence in medical practice already?  Only a fraction of medical practices are based on evidence.  In recent decades babies were immediately taken to a warming tray, briskly cleaned and swaddled tightly in blankets.  In the case of this project we were researching the best way to regulate the newborns temperature.  Not surprisingly the answer was for the mother to hold the newborn skin-to-skin (STS).  STS, when implemented properly, had the added benefits of improved outcomes for the newborn, increasing moms' level of satisfaction, and promoting the establishment of breastfeeding.  Yet out of 14 surveyed area hospitals only 2 reported STS is routine.  Clearly we are doing our newborns a disservice.

Across the literature, evidence shows STS should be the cornerstone of thermoregulation in the newborn.  The Cochoran systemic review “Early skin-to-skin contact for mothers and their healthy newborn infants,” (Moore: 2009) recognizes the irony of STS being the intervention rather than the norm.  Proper STS consistently shows to be more effective at regulating the newborns temperature than radiant warmers (Galligan: 2003; Fransson: 2005).  Moreover STS showed to have no risk of over-heating infants as opposed to incubators (Christenson: 1998).  “In addition to aiding in maintaining temperature, infants who had skin-to-skin care in the first hour were found to sleep longer, spend more time in a quiet state, and were better organized at 4 hours of age” (Mercer: 2007).

Beyond the clinical goal of regulating the neonate’s temperature, STS improved maternal satisfaction by promoting close continuous contact between mother and infant (Moore: 2009; Mercer: 2007; Maura: 2006; Price: 2005).  One review found, “90% of the mothers who had  STS care were very satisfied and 87% would prefer STS care again, compared to only a 59% satisfaction rating by the mothers in routine care group (Mercer: 2007).”  A second review stated 86% of mothers who experienced early STS had a strong preference for similar care with future births, while only 30% of mothers who held swaddled babies indicated they would prefer that method in the future (Moore: 2009).

Similarly, rate and success of breastfeeding increased with the amount of time newborns spent in close STS contact with their mothers (Moore: 2009; Price: 2005; Mercer 2007).  Babies who were cared for with STS contact had an increased likelihood to be nursing at one to four months postpartum and nursed on average 43 days longer than babies who did not receive STS contact.  These findings were regardless of country or socioeconomic factors (Moore: 2009).

Much of the literature points to the proper education of both medical practitioners and mothers alike as being the key to effective STS contact (Price: 2005; Wallace: 2001; DiMenna: 2006).  Hospitals must establish a protocol for making STS in healthy newborns the new norm.  Additional factors that contribute to the thermoregulation of the newborns need to be explored.  While STS was by far the most effective means at stabilizing a newborn’s temperature, other means of regulation included: early breastfeeding, birth room temperature at or above 77 degrees, delayed bathing, and secure swaddling when not doing STS (WHO practical Guide: 1997, Takayama: 2000).

Bibliography:

1. Christenson, K.;  Bhat, G-J.; Ahmadi, BC; Erikson, B.,  Hojer, B.  Randomized study of skin to skin versus incubator care for rewarming low-risk hypothermic neonates. Lancet. 2000 Apr 15;355(9212):1364. 
   
2. DiMenna, Lisa, MS, NNP, RNC. Considerations for Implementation of a Neonatal Kangaroo Care Protocol. The Journal of Neonatal Nursing. v. 25 n.6 Nov/Dec 2006. pp. 405-412
   
3. Fransson AL, Karlsson H, Nilsson K.  Temperature variation in newborn babies: importance of physical contact with the mother. Arch Dis Child Fetal Neonatal Ed. 2005 Nov; 90(6): pp. 500-4.
   
4. Galligan M. Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN Am J Matern Child Nurs. 2006 Sep-Oct;31(5):298-304.
   
5. Hackman PS. Recognizing and understanding the cold-stressed term infant. Neonatal Network. 2001 Dec;20(8):35-41.
   
6. Mance, Marth J., Ms, RM, NN, CPNP; Mary. A Short RN, MSN. Foundation in Newborn Care: Keeping infants warm: Challenges if Hypothermia. Advances in Neonatal Care, Feb. 2008, vol. 8 n. 1; pp.6-12.
   
7. Meng-xia, Li; Ge, Sun; Henning, Neubauer. Change in the Body temperature of Healthy Term Infant over the First 72 Hours of life. Journal oF Zhejiang University - Science A  2004 5:4, 486-493.
   
8. Mercer JS, Erickson-Owens DA, Graves B, Haley MM. Evidence-based practices for the fetal to newborn transition.  Journal of Midwifery and Women’s Health. 2007 May-Jun; 52(3):262-72.
   
9. Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2009, Issue 2.
   
10. Price, Mary; Johnson, Martian. Using action research to facilitate skin to skin contact. British Journal of Midwifery 13(3): 154 - 159 (Mar 2005)
    
11. Takayama, John I.; Teng, Weng; Uyemoto, Jill; Newman, Thomas B.; Pantell, Robert H.  Body Temperature of Newborns: What is Normal? CLIN PEDIATR September 2000 39: 503-510. 
    
12. Wallace H, Marshall D. Skin-to-skin contact. Benefits and difficulties. Pract Midwife. 2001 May;4(5):30-2. 
    
13. Department of Reproductive Health and Research (RHR), World Health Organization. Thermal Protection of the Newborn: A Practical Guide. World Health Organization: Geneva, 1997.
    

They were all waiting for me to react. “I did not go through years of medical school and have years of debt to scoop “s--t” out of a tub while you birth,” her Ob/GYN told her. As my student recounted her most recent office visit to the entire class, she started to giggle nervously and fidget. It was clear that she was unprepared for the inevitable loss of choice. While some very select MD hospitals will toy with the idea of a water-birth, most only pay lip service to the possibility; luring mothers in by giving them a false sense of ownership over their birth experiences. The mother was gracious enough to not even hint at which OB this was. She looked at me for a reaction. About 57 thoughts flew through my head, most of which I would never share with this class. I landed on, “It is not about her.”

So often in births the ownership is taken from the mother. Doctors take it, midwives take it, doulas take it, nurses take it, even machines take it. What can be left of the experience if the mother is no longer allowed choice?

Back to our distressed student 3 weeks from her due date. Other than this exchange, she is happy with her practice of OBs. I help her find ways to accommodate her preference to have water therapy available to her by offering these suggestions: a bath at home before the trip to the hospital, a shower at the hospital, the off-chance she will birth on a day with an OB secure enough in their standing to scoop poop out of a tub. I however can not resist sharing the ironic fact that regardless of this OB’s preference “s--t happens” during most births and the OB is usually the one to catch it.

Home/Birth: A Poemic was not a book I thought I would enjoy.  This was handed to me by my oldest friend over a plate of pancakes in an IHOP.  She is a poet.  I use the left side of my brain way too much.  She proved me wrong, again!  This book scratched so many different itches; my doula itch, my homebirth itch, my childbirth educator itch, my mama itch.  Are you itching to read it yet?  Don't take my word for it here is what my friend has to say.

"The writers weave together reflections on their own birthing experiences and those of their mothers with other women's birth stories, as well as facts about birthing in America today, quotes from classic natural childbirth texts, the history of childbirth in the US and much more. It's a truly insightful look at how women birth and how it impacts our whole lives, our relationships with our children and beyond. The most striking thing about it is how they manage to be both passionate in their belief that most women would do better to birth at home and yet not off-putting to someone who would make a different decision. Both women also suffered from lost pregnancies/stillbirth and they also write about how much death and loss are a part of pregnancy and childbirth. 

And it's lovely, too, very poetic even with all it includes. There are questions and phrases that they come back to again and again throughout the book, such as, Who are the villains here? ("Is the epidural the villain here?... Is pitocin the villain here?... Is the culture that fears birth the villain here?") and the idea of needing to talk ("We need to talk about it: sometimes babies die... We have hardly begun to talk about our mothers... We haven't even begun talking about how it is in the rest of the world..."). 

I definitely cried a lot reading this book, but it was more helpful than any childbirth book I read during my first pregnancy--not just more information and more stories, though that was great, but I actually feel somehow almost cleansed of fear and anxiety as I head into the last trimester of my second pregnancy. "

Who doesn't deserve a little cleansing right before a beautiful birth?

Yesterday a group of men and women met in a cozy and bright, front room on St. Paul St., in Baltimore.  We talked, we ate, we shared stories and we reveled in our love of all things birth.  There were midwives, doulas, mamas, dads, and more.  This was the first gathering of the Maryland Birth Network.  This resource will be a one stop shop for any woman/man looking for pregnancy, birth, postpartum information and support. Check it out! Monthly Birth Circle meetings begin soon.  I hope to see you there soon!