Doulas:  Before, During, and After Birth

Written by Jan S. Mallak, Certified Doula

Monday, 01 September 2008

A doula is a woman experienced in childbirth who is specially trained to provide various kinds of support for the mother before, during, and/or after the birth. The term comes from ancient Greece, where a female servant called “the doula” attended the expectant lady of the household.

A movement to bring back this age-old tradition began in 1992 when Doulas of North America was founded. Since then, several other organizations have emerged or expanded to offer doula training and certification: International Childbirth Education Association (ICEA), Childbirth and Postpartum Professional Association (CAPPA), and Association of Labor Assistants and Childbirth educators (ALACE). All can be found on the internet and offer a wealth of information regarding what a doula is, how to locate one, what costs are involved, and how to find the right “fit.”

There are three types of doulas: antepartum (before), birth (during) and postpartum (after). The antepartum doula is the newest kind of doula who can assist the high-risk mother while still pregnant, for example. The woman may be restricted to bed rest for medical reasons and therefore unable to care for herself or others. The antepartum doula can provide mother/child care, do light housekeeping, run short errands and prepare nutritious meals. She educates the mother about pregnancy, birth, or postpartum and provides her with local resources and referrals. Doulas often have a list of complimentary care providers for women to consider during pregnancy and beyond such as massage, chiropractic care, yoga, exercise, acupuncture, etc. She can recommend a variety of area childbirth classes including private lessons if a mom is on bed rest. The doula can also lend an ear to help the mother deal with the additional fears associated with a highrisk pregnancy and possible outcomes. And she helps keep the family on track so their lives can flow more smoothly even if mom is “out of commission.”

Sometimes an antepartum doula is called in to help an expectant mother shop or set up for the baby. Maybe the mom simply has no family in the area and needs assistance with some of the basics associated with preparing for a new baby. Having an experienced woman’s guidance and companionship can be very instructive and reassuring for the mother-to-be.

A postpartum doula does much the same as the antepartum doula, but after the baby comes. Her roles are similar but helping the family transition into their new life with the baby is now the focus. Education often takes the form of “on the job training” since the baby has specific, immediate needs that have to be met. Bathing, dressing, changing, swaddling, feeding, burping and entertaining the baby are some of those immediate needs. And, not everyone feels very accomplished in those areas. The doula steps in to educate, guide, and facilitate the family’s comfort and confidence with their new roles.

Breastfeeding is on the rise, so assistance with nursing is another function of the postpartum doula. Many women lack breastfeeding role models or reliable resources; having an experienced and knowledgeable guide is a valuable benefit for them. Helping the baby latch on well from the beginning seems to really contribute towards early breastfeeding confidence and success. Follow-up and suggestions on almost a daily basis from a doula help the mother maintain her self-belief.

Postpartum depression is also on the rise so having someone around who knows how to prevent, recognize, or deal with postpartum mood disorders can literally save lives. Sometimes a woman’s birth experience can influence her mental state. A debriefing afterwards can be very therapeutic. Doulas are trained to be good listeners, assess a woman’s well being and refer if warranted. No medical care, advice, or interpretations is ever provided by any type of doula. Doulas identify red flags and provide expert resources and referrals, which are integral to their duties. Sometimes the father experiences a postpartum depression of sorts due to little sleep, improper nutrition, new roles and responsibilities, worry, etc. The doula is there to help the whole family with all the new adjustments and challenges and can address these issues as well.

A birth doula is quite different from the other two types of doulas. She specifically helps a woman prepare for the birth, deal with it, and recover from it. She provides five types of support: physical (like a personal handmaiden), emotional (like a trusted friend), informational (like a walking textbook), mediatorial (like a nurturing protector), and spiritual (having a special woman-to-woman connection). Because every woman’s response to labor is different, the doula must be able to meet her clients’ particular needs. Meeting before the birth, working on a birth vision jointly (like a birth plan), going to an appointment together, attending the birth, helping with bonding and nursing and visiting afterwards creates a trust relationship that develops over time. When the mother develops this comfort with the doula and confidence in the birthing process she tends to have a safe, satisfying, and successful birth. The “wrap-around care” that a doula offers is not provided by any other member of her birth team—it is a truly a unique and special relationship.

Research since 1980 shows that there are many benefits to having doulas: shorter labors, less interventions used, fewer cesarean deliveries, more satisfying birth experiences, more successful breastfeeding, and decreased postpartum depression to name a few. Even though a doula can dramatically reduce the cost associated with births, insurance companies do not routinely cover their fee. Some couples participate in a tax-free employee benefit plan at work which reimburses for medical expenses not usually covered by traditional health insurance. Doula fees are sometimes paid in that case. It’s worth contacting an insurance company or employer to investigate this possibility.

Some worry that the doula might take away from the partner’s role at the birth. In fact, research shows the opposite: dads are more involved because the doula guides, suggests, and models roles for them to follow. She helps them find their comfort level and watches over their well-being, too. After all, he needs to be the rock for the family when everyone disappears after the birth. It is critical for the doula to safeguard dad’s stamina and ability to function as a new parent. She also gives him the opportunity to take a break or eat a hot meal or go for a brisk walk, guilt free. This removes the total responsibility of the mom’s labor support off his shoulders. And he gets to be in the first family photos instead of taking them…that’s a real bonus! Lastly, a doula is fond of her client but does not love her so she doesn’t get swept away emotionally like a family member might. This caring detachment is a real plus when facts need to be gathered or difficult decisions need to be made.

Others wonder why a doula is needed if staff is there. Medical staff work in shifts and go on breaks, so caregivers change often. They also have more than one patient so they go room to room. Also, the staff does not know the parents like a doula does. Some births take place at the client’s home so there is no staff on duty at all.

Some question why a doula would be necessary if using a midwife. Even though their roles overlap, the midwife is still in charge of the medical care whereas the doula’s job is strictly one of “social” support. Midwives need breaks too, for sleep or to eat to be medically ready. But a doula can perform her duties half asleep and hungry and still be effective! Since doulas and midwives tend to have similar birth philosophies, working in alliance for the client’s benefit is especially advantageous.

Giving birth is a rite of passage for a woman so pregnancy, delivery, and postpartum should be a special time for the mother. By hiring a doula to assist during this unique phase in a woman’s life, she can truly feel well-educated, supported and assisted. This combination leads to feeling empowered and confident. After all, generations of women have been helping other women to prepare for and to deal with being a new mother. Why shouldn’t modern women consider taking advantage of a tried and true system that has worked for thousands of years?
View article references and author information here: www.pathwaystofamilywellness.org/references.html

This article appeared in Pathways to Family Wellness magazine, Issue #19.

The Birth Marathon: Food & Drink for Labor & Birth

By Patty Brennan, BA, CD(DONA), PCD(DONA)
Excerpted from Brennan’s cookbook, “Whole Family Recipes:  For the Childbearing Year & Beyond” © 2007

Women birthing in most hospitals are told that they cannot eat during labor and can only drink clear liquids once they are admitted.  The reason behind these instructions is to prevent aspiration of stomach contents in the rare instance that the mother requires general anesthesia for an emergency.  The following are tips to enhance energy and progress in a mother if her labor goes longer than her blood sugar can hold out.

Strategies

Some women experience an urge to load up on carbohydrates in the 24-hour period before the onset of active labor, similar to what an athlete may do in preparation for running a marathon on the following day. Go for it! (I had a bread, salad and pasta dinner at a local restaurant 12 hours before my second child was born and never felt nauseated in labor, which started about five hours after the meal.) This strategy is especially recommended for women facing a scheduled induction. Avoid having the hard work to hit after essentially fasting for 24 hours or more.

EAT IN EARLY LABOR. This is essential and must be maintained throughout the day. Don’t just settle for breakfast and stop there. Eat every 2–3 hours, whatever is appealing. You may want to avoid heavy, greasy foods such as pizza or fast food (which don’t digest easily under the best of circumstances).

Avoid substances that will cause a blood sugar level spike, such as soda and other forms of concentrated sugar (read labels!). These are dehydrating and ultimately lead to blood sugar crashing.

If planning a hospital birth, eat a banana on the way to the hospital. Despite most TV depictions of how women go into labor (i.e., a sudden contraction alerts her to the need to rush to the hospital where she gives birth soon after on her back, typically involving various emergencies for dramatic effect), most women have plenty of time to take care of themselves with little need for high drama.

During labor, try a variety of the suggestions below, alternating them. A little protein here, some electrolytes there, something sweet to boost your energy, the Pregnancy Tea—you get the idea. That will keep a mom going if the labor is long.  This is especially important for women who might be admitted to the hospital early in labor or whose labor is being induced.

Drink lots of water, at least 4 oz per hour throughout labor, more if it’s a hot day and you’re sweating a lot. Have your support team help you with this. (Note to all attendants: Your job is to encourage the mom to drink throughout her labor. If she is willing to drink, asking for liquids and consistently taking several gulps when offered, then just keep the supply coming and keep an eye on her to ensure she doesn’t stop drinking at some point. However, if the mom is disinterested in drinking and reluctant to do so, then frequent small sips will be necessary. Keep offering!)

Finally, don’t hesitate to accept IV fluids if you can’t keep anything down over a long period of time and are getting dehydrated. While healthy women will not need routine IV fluids, dehydration can cause your labor to be dysfunctional and non-productive. An IV can turn the picture around and is an appropriate use of medical intervention.

Recipes for Nutritious Clear Fluids

Raspberry leaf tea labor cubes. Before labor begins, make up a very strong tea (two quarts of boiling water with two cups of dried red raspberry leaves added).  Simmer with the lid off for at least 20 to 30 minutes as the volume reduces considerably. Strain and add one quarter cup of honey (raw is best if possible).  Pour into ice cube trays and freeze, adding water if necessary for at least one tray’s worth.  Store in a zippy bag at home or take with you to the birth center/hospital.  (Usually you can store them in the freezer of the small room refrigerator or in the common nutrition room refrigerator).  The honey gives mom a boost of energy, while the concentrated raspberry leaves provide minerals and may assist in bringing back strong contractions.  In between the contractions, mom can easily crunch the cubes into a satisfying slush.

Electrolyte-balanced sports drinks. There are a large variety of sports drinks on the market these days.  Avoid the overly-sweet, chemically-generated metallic blue and other colored products not found in nature.  Encourage mom to see what is available at her local health food store and experiment until she finds one she likes.  Recharge is my personal favorite and is available in several flavors. Have two to three quarts on hand for labor.

Miso broth. If you are unfamiliar, miso is a paste made from fermented soybeans.  It is high in protein and tastes salty.  If you haven’t tried miso, there are a number of different flavors available in the refrigerated section of your local health food store.  Give them a try and find one you like.  The paste can be brought with you to the hospital and kept in the refrigerator.  Mix one tablespoon of miso into one cup of hot water.  Avoid boiling miso as it kills may of the nutrients.  There are also packets of instant miso soup on the market.

Concentrated homemade chicken or beef broth. Place one whole (preferably organic) chicken or a couple of beef bones in a large soup pot.  Bring to a boil and spoon off the scum that will rise to the surface over a 10 minute period and discard.  Roughly cut up one onion, three carrots (washed, with skins on) and three stalks of celery, including tops.  Chop up two to three garlic cloves and throw those in too (you can even leave the skins on as a timesaver).  Cover and reduce heat, simmering for one and a half hours or more.  Cool and strain out the solids (make chicken salad with the meat).  Put the broth in the refrigerator overnight so that the layer of fat on top solidifies.  In the morning, remove and discard the fat layer.  Return the broth to the stove, uncovered and bring to a boil, allowing the liquid to reduce to a rich-colored (and tasty!) broth.  Add in Celtic sea salt (for the extra minerals) to taste at the very end.  Freeze in small containers to have on hand for labor.

Herb tea and honey. Encourage mom to bring a variety of her favorite herbal teas and some raw honey with her to the hospital.  When energy flags, especially in the second stage of labor, a cup of tea with a generous spoonful of honey can give her the boost she needs to get the job done.  Ginger tea may help settle the stomach if nausea is an issue.

Hot drinks. Americans are big on iced drinks, but in many parts of the world, ingesting iced drinks is not recommended.  An number of cultures, from China to South America, have prohibitions against iced drinks for women in labor or postpartum.  The wise women grandmas-to-be will not allow it.  Feed the fire.  Women are supposed to get hot in labor!  She will sweat.  She will be uncomfortable.  It’s okay.  It’s more efficient.

“With over 7000 birth and postpartum doula members and growing, we are the largest doula association in the world. We support doulas by providing quality training and meaningful certification. We serve mothers and families by providing access to information and research about doulas, childbirth and the postpartum experience. DONA International certification sets the bar for doula education and professional development. It indicates to families that a doula has achieved a high level of training and professionalism.”

To become a DONA International certified birth doula:

The majority of the dads that I have had the privilege of working with as a doula (some of them are pictured here) have said that having a doula there allowed them to become more involved in the labor than they would have been if I had not been present.  Each time I hear this, I am reminded at how opposite this is from what people assume about a doula and a dad’s role at a birth.  A good doula doesn’t take away from the good things that are happening between a dad and a mother.  If they are doing well on their own, then she steps back and is respectful of that.  The intimacy that they share is a very valuable element in the birthing “team”.  He knows his woman far better than the doula does and can speak to her needs with wonderful intuition at times.  I love seeing that unfold between a couple.  However, the doula’s role is a wonderful complement to what a couple can do on their own.  Penny Simkin’s article below explains some of the myths on this subject:

~Andrea

The Doula and the Partner: How They Work Together to Help the Birthing Woman

by Penny Simkin, P.T.

When a doula discusses her role with women or couples, she may feel a little uneasy when asked exactly what she has to offer. She may find it difficult to give an answer that reflects her usefulness without seeming that she is bragging. The most common question regarding doula care for birthing couples: what about the woman’s husband/partner/loved one? There are many valid concerns often raised by couples considering doula care for childbirth. For example:

1. Partners who have taken childbirth classes may wonder, “Why bother with a doula?” The classes theoretically prepare the father or loved one for that role, and it appears that a doula is redundant.

2. The doula might interfere with the couple’s intimate experience, since she is nearly a stranger to them.

3. The doula may try to make the woman have the kind of birth the doula wants, not what the woman and her partner want.

Some couples worry that the partner will be pushed out, that the doula will assume that she can do the job better and will relegate the partner to a minor role. On the other hand, some women worry that their partners will not be able to help very much, but are hesitant to suggest a doula for fear of hurting the partner’s feelings. And some partners want help, but they feel insecure about their ability to meet all of their wife’s or loved one’s needs.

Here I will discuss some of the myths or concerns about doulas, along with the realities. They may clarify how a doula works with a woman’s partner.

Myth #1: If a woman has her partner, the doula becomes redundant.

Reality: The doula may be the only person at the labor beside the partner who is there solely for the emotional well-being of the woman. The nurse, the doctor, the midwife have other priorities that compete with the emotional care of the woman; for example, breaks, shift changes, clinical responsibilities, office hours and hospital policies. The doula has few or no other priorities. She stays through shift changes, and until after the baby is born. She is not just another stranger with the couple. She has the woman’s needs as her sole priority.

In some cases, the couple will bring several other friends or family members into labor with them. Sometimes these people can be uncertain of how to help, which leads to confusion and actually adds to the woman’s stress. The doula can direct and coordinate the efforts of a group of people, giving them all something useful to do, so they work as a team on the woman’s behalf.

Myth #2: The doula “takes over,” displacing the partner and interferes with their intimate experience.

Realities: The doula can actually bring the couple closer. By making sure that the partner’s needs are met (food, drink, occasional back rubs, and reassurance), the woman and partner can work more closely together.

The doula allows for the partner to participate at his or her comfort level. Some partners prefer to be there only to witness the birth of their child and to share this experience with the woman they love. They may not want to play an active role and do not want to be responsible for the woman’s comfort and emotional security. The doula can fill in and allow the partner to participate as he or she wishes, without leaving the woman’s needs unmet.

When the partner chooses to be the major source of emotional support, the doula can supplement his or her efforts by running errands, making suggestions for comfort measures, and offering words of reassurance, and comfort. During a long tiring labor, she can give the partner a break for a brief rest or change of scene.

For the partner who is shy, uncertain, or unversed in his or her role, the doula suggests simple but truly useful tasks, such as timing contractions, holding the woman, supporting her in a particular position, massaging her. In such situations, the doula might take the lead, but the partner plays an important secondary role.

While the doula probably knows more than the partner about birth, hospitals and maternity care, the partner knows more about the woman’s personality, likes and dislikes, and needs. Moreover, he or she loves the woman more than anyone else there. The combined contributions of partner and doula, along with a competent, considerate and caring staff give the woman the best chance of an optimal outcome.

Myth #3: The doula has her own beliefs about how the birth should go, and imposes it on the woman or couple.

Reality: The doula’s true agenda is to help ensure that the woman’s or couple’s agenda (their birth plan) is acknowledged and followed as much as possible. If the doula is thoroughly familiar with the couple’s wishes and their birth plan, she may actually think more about it than the couple, especially when labor is intense and things are happening rapidly. The doula can remind the staff or the couple of some items on the birth plan that are forgotten, but which later might be important. Sometimes if a birth plan is not followed, the couple later look back with regret or disappointment.

The doula helps with decision-making by asking questions that will ensure that the right information is given to the woman or couple so that they can make an informed decision. She may also suggest alternatives (like waiting awhile) for the couple to consider. She does not, however, make decisions for the couple.

In summary, the doula helps make the birth experience to be as rewarding and satisfying as possible. As one father said, “I heaved a big sigh of relief when she (the doula) walked in. I hadn’t realized how much pressure I had been feeling. She not only calmed my wife, she calmed me down.”

Click HERE to read another article on dads and doulas.

You might be wondering if there is a point to having a birth plan for labor, birth and postpartum care for a mother and her baby.  Do the caregivers even look at the plan?  Will making one just set the mother up for disappointment if everything doesn’t work out exactly how she wanted it to?  Is it just a waste of time since birth can’t really be planned?

I tend to feel that creating a birth plan is a great way to educate yourself during your pregnancy about your choices and evaluate the risks and benefits of different interventions.  If you were looking into buying a house or a car, you would look at all the different features, research all your options, ask questions and evaluate the answers before buying one.  So why wouldn’t you have the same approach when it comes to the birth of your child?  However, I also feel that creating a birth plan can be driven by fear of things outside of our control and it is important to be clear about the purpose of a birth plan.

Finding a balanced approach to birth plans can be tricky.  Marsden Wagner describes a birth plan as, “an approach to labor, rather than a term for a specific kind of outcome” (Wagner 1).  He views a birth plan as a tool to be used to work toward a woman-centered childbirth.  Even though many aspects of labor are impossible to plan for, it is still the mother’s right and responsibility to be fully informed about the different types of maternity care available to her.  Pam England is more cautious of birth plans because she feels that it can distract a mother from trusting herself and her body for what she needs at different moments during labor.  “All women ask for the same thing:  respect, dignity and support to birth naturally with minimal routine intervention and no unnecessary separation from the baby” (England 97).

Since birth can’t be planned, it might make more sense to call a birth plan a birth guide.  This better defines what it is- a guide for your support team and caregivers to use along with you while you make decisions during childbirth.  “Remember, your birth plan is a wish list.  Its purpose is not to control birth itself, since birth, as a force of nature, is actually under no one’s control.  Rather the birth plan aims to educate you, help you make decisions and communicate them to your caregivers, and thus, to influence the care you receive” (Wagner 219).

So are birth plans important?  I feel that they are, as long as they are approached with the full knowledge that they are meant to be flexible and the main goal of putting one together is to educate yourself.  Childbirth is such an important time for a mother and it shouldn’t be looked upon lightly.  “Producing a healthy baby is a major goal of birth.  But a successful birth outcome involves so much more than mere survival.  We should not disregard the human impact of childbirth.  Positive laboring experiences set women up to become good mothers and more confident people.  Some people climb mountains or run marathons to find out what they are capable of.  Giving birth presents a comparable opportunity for the woman who decides to become a mother.  It can reveal her to herself and transform her self-image” (Wagner 4).

If you’d like to learn more about the different aspects of care to consider when writing your birth plan and for specifics suggestions for putting your plan together, I will be leading a Create Your Birth Plan class through Mommy Matters Online along with local Fresno doula, Gena Kirby.  Click HERE to schedule a spot for you and your partner today!

Sources Used

England, Pam, and Rob Horowitz.  Birthing From Within.

Wagner, Marsden, and Stephanie Gunning. Creating Your Birth Plan:  The Definitive Guide to a Safe and Empowering Birth.

They all encouraged me to get involved with Childbirth Resource Network (CRN) a network of parents, birth professionals and other service providers in the central San Joaquin Valley. CRN’s goal is to help guide anyone seeking to know more about their options in creating a healthy and happy pregnancy, childbirth, and transition to parenthood.

So I got started right away attending CRN meetings and doing my best to connect with other birth professionals in the area.  In the meantime, I was also working hard to plug away at the other requirements for my doula certification through DONA (Doulas of North America).  For more information on requirements for doula certification, click HERE.

Through Amy, I was able to attend my first birth in June of 2009.  Amy had asked me to be her “back-up” doula since she knew she would be going out of town close to the mother’s due date.  I was able to meet the mother beforehand and get to know her and what she was hoping for in her birth experience.  After attending the birth in June and getting the business part of my doula work set up, I was ready to go.  Things have been moving at a good pace ever since.  I feel blessed to have been present for five births (as of today) as a doula.

In some ways, I had to be very outgoing to get the information I needed to get started.  I had to gather a little from one place, a little from another and glean what I could while trying to maintain organization all at the same time.  A few months ago, I started getting emails and phone calls from other ladies in the area who were wanting to become doulas in the central valley.  They were calling me for some of the same advice that I had been seeking just a short time ago.  I then learned that my doula trainer would be returning to the area in March of 2010 to do another training.  The doula profession seemed to be growing quite suddenly and I found this to be very exciting.

Some of us “veteran” doulas have decided to set up regular doula meetings so we can learn from each other and help the newer ladies get started.  As of now, a directory of sorts is being compiled so that it will be easier to find all the doulas in the area, all in one place.  You can check it out by clicking HERE.

I’ve also started to partner with Mommy Matters Online to do back up for births and to help teach classes.  Mommy Matters offers a wealth of information and resources to pregnant women and new families alike.  I’m proud to partner with the other doulas in this area.  We are all doing what we do for the same reasons- to educate, support and nurture parents as their families evolve.

I have been married to my wonderful husband for 8 years and we have two boys ages 4 and 2. My boys are lively and bursting with personality. They definitely keep me on my toes!

There were many different factors that influenced my journey to “birth world”. I started out in college wanting to be an elementary school teacher and although I did over a year of substitute teaching during that time, I decided I wanted to go a different route with my career. After getting my Bachelors Degree, I worked for 2 ½ years with a local mentoring program but decided to stay home once my son was born. When he was almost 1, I did some tutoring for elementary aged kids for awhile, then I worked at my church a few afternoons a week maintaining their website. Things got a bit busier when my husband and I welcomed our second son into the world before our oldest had turned 2. Needless to say, we’ve got our hands full! I am currently able to be home full-time, excluding my work as a doula. It has been my pleasure to stay home with my boys.

Becoming a doula was something that I really started thinking about after the birth of my second son. For me, giving birth both times had been so empowering, emotional, exciting and wonderful all at the same time…not to mention, extremely hard work! I just felt this strong desire to share my experience with other women through helping them during this unique and special time in their lives. I feel that as a doula, my role is to help you have the most satisfying birth possible- as defined by you.