Birth Doula FAQs

What’s a doula?
A doula is a woman experienced in childbirth who provides continuous physical, emotional and informational support to the mother and partner during pregnancy, birth & early postpartum. In much of the world today and throughout history, women support women through labour & birth.

What’s the difference between a midwife and a doula?
Doulas work as part of a team with doctors or midwives, but not instead of. They provide non-medical support and comfort measures (e.g. encouragement, massage, positioning suggestions). They do not perform clinical tasks such as heart rate, blood pressure, or internal exams.

Midwives are highly trained in the medical aspects of birth. The carry oxygen, medicines, resuscitation equipment and other gear, and are known as primary care-givers during birth. In North America primary/medical birth care is offered by either a midwife or a physician.

Why choose a doula over simply using a friend or family member as support?
Doulas are trained and experienced in childbirth support. They know the sounds and behaviors of laboring women, and what that may indicate about progress. Doulas are trained in pain-reducing comfort measures, natural methods to keep labor progressing, and to support both the laboring woman and her partner. Doulas are familiar with local hospital policies & practices and have often built a rapport with the doctors, nurses and midwives. See http://evidencebasedbirth.com/2012/06/26/why-wouldnt-you-hire-a-doula/

In most Canadian hospitals, women are allowed 2 support persons – usually that’s her partner and a support person. Some hospitals accommodate a 3rd support person. Homebirths and birth centers encourage women to have all the support they wish.

How does the doula fit in with nursing staff?
Doulas do not replace nurses or other medical staff, but rather work as part of the team. They are there to comfort and support the mother & her partner. Nurses change shifts; doulas stay.

How does a doula assist with communication in hospitals during labor & birth?
During prenatal meetings doulas learn what’s important to a couple and discuss how to make informed decisions. A doula may remind or encourage a client to ask the questions necessary to understand a procedure and make informed decisions. Doulas do not speak on a client’s behalf nor intervene in their clinical care. They do not make decisions for clients, nor judge the decisions clients’ make, but are there to support those decisions.

What difference does the presence of a trained doula have on birth outcomes?
The presence of a doula tends to result in shorter labours with fewer complications and less interventions. When a doula is present during and after childbirth, women report greater satisfaction with their birth experience, make more positive assessments of their babies, have fewer caesareans and requests for medical intervention, and less postpartum depression. In case of unplanned circumstances, doula support helps reduce negative feelings about one’s childbirth experience. Studies [1],[2],[3],[4]   have shown that babies born with doulas present tend to have shorter hospital stays with fewer admissions to special care nurseries, breastfeed more easily and have more affectionate mothers in the postpartum period.

Analysis of six randomized trials1 demonstrates that lack of doula presence correlates with:

  • Double the overall caesarean rate
  • 33% increase in length of labour
  • 67% increase in oxytocin use
  • 2 ½ times more requests for epidurals

Will a doula make my partner feel unnecessary?
A responsible doula compliments and enhances the father/partner in their supportive role rather than acting as a replacement. (While I respect people’s individual circumstances, I will use “father” words for most of this paragraph.) The presence of a doula allows the father to support his partner emotionally during labor & birth without the pressure to remember everything he learned in childbirth class! The father typically has little-to-no actual experience with the birth process, yet is expected to act as a coach. Some partners feel (accurately) that this is a huge expectation. Many fathers experience the birth as an emotional journey of their own and find it hard to be objective. A doula is supportive to both the mother and her partner, and plays a crucial role in helping a partner become involved in the birth to the extent he/she feels comfortable. Studies have shown that fathers usually participate more actively during labor with the presence of a doula than without one.

When a couple works well together during the birth process they’re better able to handle the challenges of early parenthood. An incredible bond forms or is made stronger.

How often and when do we meet?
We’ll meet 2-3 times before the birth. The introductory meeting is any-time – it’s never too early. The prenatal meetings are best done between 24-36 weeks. After your baby is born there will be a minimum of one postpartum visit, more if needed or desired.

Are doulas only useful if planning an un-medicated birth?
The role of the doula is to help attain a safe and pleasant birth, not to choose the type of birth. The presence of a doula is beneficial no matter what type of birth you are planning. In fact, women who choose a medicated birth need as much support as those who choose a natural birth, but a different kind of support. For women who know they want a medicated birth, the doula still provides emotional support, informational support and comfort measures to help the women through labor and the administration of medications. Doulas can help a mom deal with possible side affects and by filling in the gap that medication may not cover; rarely does medication take all discomfort away.

For a mother who faces a cesarean, a doula provides comfort, support and encouragement. Often a cesarean is an unexpected situation and moms are left feeling unprepared, disappointed and lonely. In this case doula support is especially helpful during the early postpartum period.

What if I planned a drug-free birth then change my mind during labour?
Doulas don’t make decisions for clients or intervene in clinical care, nor do they judge women’s choices. They provide informational & emotional support while respecting a woman’s decisions.

What kind of comfort measures do you use during the labour & birth process?
While there are common comfort measures taught in doula training courses, each doula also brings her own tools and methods. Ours include the following:

  • Positioning suggestions
  • Massage & various touch methods
  • Homeopathy & Bach Flowers (optional; no extra charge)
  • Aromatherapy
  • Encouragement & reassurance
  • Heat or cold as desired
  • Hydrotherapy (water for comfort in labour, and/or water-birth)
  • Create space for partner, and recommendations to help partner to offer support
  • A calm, reassuring presence who trusts the birth process

When do we call you in labour?
Please call at the first signs of suspected labour. We’ll discuss what those are. From then on you’ll keep us posted on your progress and what’s happening.

When and where do you join us in labour?
When depends on the woman, her partner, and the labour. Early support often takes the form of checking in by phone and/or dropping by your place.  Your doula joins you either at your home or in hospital or birth center and remains with you until 1-2 hours after the birth.

How does shared-care work?
Doulas team up to provide enhanced service. Clients benefit from combined experience, education, and availability. Since doulas are on call for up to a month for each client, shared care allows them time for important life events and days off without having to turn clients away or rely on unfamiliar back-up. Clients meet both doulas prenatally so they’re familiar with whichever one attends birth.

What if you can’t be at the birth?
In the rare circumstance that one of your doulas can’t be there, you will be well supported. We work with reliable back-ups who offer excellent care. Fees remain the same. If the back-up is likely to be part of care, some clients wish to meet her prenatally, which can be arranged.

Do we pay more to work with 2 doulas?
No. Fees are outlined in the contract. The cost of working with both doulas is the same as hiring one of them individually.

What kind of postpartum support do you offer?
Your birth doula usually stays for 1-2 hours after the birth, until you’re ready to be on your own with your baby. We also visit in the first day or two postpartum, offering basic breastfeeding support, answering questions, and going over your birth. We are available for questions and can offer resources (educational and community). A second postpartum visit is offered.

What if I need extra help with breastfeeding or baby-care?
The information above describes our work as birth-doulas. Another kind of doula, a “postpartum doula”, specializes in extended care and breastfeeding support. There are also breastfeeding counselors and lactation consultants that can be arranged through public health or hired privately. We can provide resources and contact info. If you’re on the Mother-Baby Unit the nurses or unit Lactation Consultants can provide support.

Where’s that name from?
In ancient Greece “doula” meant the highest female servant who helped the lady of the house through child-bearing. Medical researchers Marshall Klaus and John Kennell, who conducted several randomized clinical trials on the medical outcomes of doula attended births, adopted the term to refer to labour support as well as prenatal and postpartum support.

 

[1] Klaus, M.H.; Kennel, J.H.; Berkowitz, G.; Klaus, P. “Maternal Assistance and Support in Labor: Father, Nurse, Midwife or Doula?” Clinical Consultations in Obstetrics and Gynecology 4 (December 1992).

[2] Sauls, DJ. Effects of labor support on mothers, babies, and birth outcomes. J Obstet Gynecol Neonatal Nurs. 2002 Nov-Dec; 31(6):733-41.

[3] O’Driscoll, K. and Meagher, D. Active Management of Labor. 2d ed. London: Bailliere Tindall, 1986.

[4] Klaus, M.H. and Kennel, J.H. Parent-Infant Bonding. St. Louis: C.V. Mosby, 1982.

Essential Herbal Tea for Pregnancy & Breastfeeding

Women have consumed infusions (tea) of Red Raspberry leaf and Nettle leaf through the ages for a healthy childbearing year, healthy reproductive organs at any stage of life, and to keep their skin soft and supple.  This blend is very high in easily absorbed minerals.  If no milk or sugar is added then this drink counts toward your daily water intake.

Drink 1-3 cups of Pregnancy Tea, hot or cold, daily through first 2 trimesters, and 3 cups during last trimester. 

Combine these teas in any ratio you wish, but the general recipe is:

  • 2 parts Red Raspberry Leaf
  • 2 parts Nettle Leaf
  • 1 part Horsetail Leaf (added for calcium & strong bones)
  • Optional: 1 bag or small scoop of lemon, berry/fruit teas (ensure no licorice), mint or lemongrass to change up the flavour.

A batch can be stored in the fridge for up to 3 days.

Red raspberry (Rubus idaeus)

  • Most commonly used and well-known pregnancy herb
  • Tones female reproductive system; also pelvic and uterine muscles
  • High amounts vitamin C, easily assimilated calcium and iron
  • Also vitamins E, A, B-complex, many minerals inc phosphorus and potassium
  • High mineral content helps tissues stretch, decreases stretch marks, helps prevent anemia
  • Lower rates of miscarriage and postpartum hemorrhage
  • Prepares body for labor. Therefore decreases pain and length of labor.  Doesn’t strengthen contractions but makes them more efficient.
  • Help expel placenta
  • Good for morning sickness

Nettle (Urtica dioica)

  • High amounts of virtually all mineral & vitamins needed for health
  • Especially high in A,C,E,D,K, calcium, potassium, phosphorus, iron, sulfur
  • High amounts of chlorophyll (for energy and nutrients, vitamin K)
  • Nourish and strengthen kidneys; gently dislodge and dissolve any mineral buildup
  • Relax leg cramps and muscle spasms
  • Prevent hemorrhage after birth due to high vitamin K
  • Strengthens blood vessels, therefore good for hemorrhoid prevention
  • Astringent for hemorrhoids
  • Increases quality of breast milk

Other herbs high in easily-assimilated vitamins and minerals (alone or added to the above teas) include Horsetail a.k.a. Shavegrass (very high in calcium), Alfalfa and Kelp.

Several other herbs are safe during pregnancy and are tasty e.g. mint.  Some aid pregnancy related issues such as nausea, heartburn, cramping, and constipation to name a few.  These include but are not limited to ginger, chamomile, slippery elm bark, and fennel.  Consult a qualified herbalist with knowledge of pregnancy herbs before taking any.

By the way, this tea is healthy for the males in your life too, and is safe for all ages from infancy on.  It’s a lovely, mildly flavoured drink for the whole family.

Prefer pre-packaged tea?  Health stores and quality Mama/Baby stores sell pregnancy tea, e.g. Earth Mama Angel Baby “Third Trimester Tea” (which you can take in any trimester).

Breech Baby – What You Can Do Prenatally

“Breech” is a term describing your baby as head-up rather than the optimal head-down position.  Breech position is not uncommon in the middle of pregnancy and most babies turn head down toward the end.  Some turn during labour.  A baby coming bottom first can have more difficulty being born and while a caesarean birth may be suggested, there are many doctors willing to catch breech babies.  For now let’s focus on turning the baby.   The best time to turn the baby is around 35 weeks.

Home Birth Supply List

Prepare Your Home Before 37 weeks:

  1. Midwife & doula contact info on your fridge; info entered into cell-phones
  2. Other “Important Phone Numbers” list on your fridge
  3. Purchase / rent birth pool if applicable, and plan for set-up
  4. Some cleared surfaces for equipment set-up
  5. Plan for birth-attendant parking
  6. Outside lights working, house # visible at night (may require a temporary # to be put up)
  7. Clear path to door and through halls
  8. Child-care plan (unless they’re attending birth; MW & doulas can offer tips)
  9. Pet-care plan – pets with teeth / claws absolutely need to be locked up or sent elsewhere as even the most gentle animal can become over-protective and stressed while mama’s in labour
  10. If you’d like candles then please use only unscented beeswax or battery-candles
  11. Get your bed “birth-ready” – make bed in this order (from bare mattress): extra mattress pad, sheets for after the birth, then a plastic sheet, mattress pad (optional but nice), sheets for birth, blankets & pillow cases that can be used for birth.  Have pillow cases and blankets for after the birth nearby.  Note: if you don’t wish to sleep with plastic in the days/weeks before birth, please have all this ready near bed so someone can quickly make the bed during labour.
  12. Birth-Kit from MW (if she provides this; otherwise purchase and assemble yourself):
    – Package of 10 or more large absorbent under-pads / “blue pads”
    – Peri-bottle for postpartum perineal care (one per washroom)
    – 4 pair disposable mesh underwear
  13. If you have a guest-room, it’s nice to have it ready for birth-attendants, just in case

Birth Container

Please prepare in a box, plastic tub or reserved laundry basket.

 1) Dryer Items
These items will be warmed in the dryer prior to birth.  Place in a separate bag or container (but keep it with Birth Container). Washed and ready for use; will get soiled or stained so consider Thrift Store purchases.

  • 6 towels (more for waterbirth!)
  • 6 receiving blankets
  • 2 hats for baby
  • 3 flannel sheets/blankets for mother

2) Other Linen
Washed and ready for use; will get soiled or stained so consider Thrift Store purchases.

  • Newborn outfit incl. diaper, undershirt, sleeper, socks, hat and blankets
  • Nighty / PJs for mother
  • Set of sheets to fit bed
  • 6 old washcloths, old diapers, etc. for hot compresses
  • 10 washcloths for mother comfort
  • 6 towels; make it 12 minimum for waterbirth!
  • 10 cloths/rags for clean-up after

3) Other Items
Note: There may be some repeats from the Birth Bag Suggestions list, which you’re encouraged to check out for some great ideas of things you can use at home, hospital or birth centre.

  • Large plastic sheet to protect bedding – e.g. drop sheet or plastic shower curtain liner
  • 4 large garbage bags (1 for soiled laundry, 1 for garbage, plus 1 replacement each)
  • Large saucepan or Crockpot for heating compresses and oils
  • (optional) Small unopened bottle of food-grade oil e.g. olive or grape-seed for crowning
  • Plastic ice cream pail or other suitable container with lid for placenta
  • Flashlight with new batteries
  • Large pkg. maxi pads, extra long (the bigger, thicker the pad the better). Avoid pads with a “dry-weave” topping as they can be irritating to your perineum
  • Flexible straws
  • Cookie sheet or other large firm portable surface
  • Bottle of hydrogen peroxide
  • Digital thermometer
  • Q-tips, in case of care of umbilical cord

4) Waterbirth
Your pool should have come with a supply list.  Please ask if you need more info.  If you’re lucky enough to have a big comfy built-in tub, the only extra thing you’ll need is a floating thermometer and a small fish-net or sieve.

Nourishment

Think about lots of healthy foods and drinks (Labour-Drinks) you and your family might enjoy during and after labour and birth, and stock up.  HINT– birth attendants LOVE tea and snacks too! 😉

Make a few trays of ice-cubes (can keep cubes in a zip-lock).

Waterbirth Info

Natural physiologic birth leads to a safer and gentler birth for both mother and baby.   Labour hormones (including higher levels of pain-killing endorphins) work optimally when a labouring woman feels safe, private, unobserved, and uninterrupted.  Labour proceeds faster, with more efficient contractions, less pain perceived, and fewer complications (Buckley, 2004).  Women can relax, surrender and sink deeper into labour.  This results in fewer interventions.  Water birth helps facilitate an environment of privacy, calm, and quiet.  Several studies of labour in water vs. land report positive findings.  Others found no differences but also reported no adverse outcomes, no increase in interventions, nor poorer outcomes.

Mother Benefits

Easier, faster labour:

  • More support: mother isn’t left alone and partner can get in pool to provide close support.
  • Reduced inhibition as mother feels supported and less exposed.
  • Buoyancy allows for easier mobility and relaxed muscles. Less work is used for support and upright positions.  This especially helps women with a physical disability, injury, body-pain or mobility issues to assume positions they may not be able to hold or achieve on land.
  • Fewer vaginal-exams and other interventions.
  • Less back-labour.
  • Easier delivery. Greater pelvic diameters; low back and pelvis aren’t compressed.
  • Fewer & less severe tears with natural counter-pressure on perineum.
  • Less fear & pain with birth.

Pain reduction:

  • Warmth and skin-contact of water may close the “pain gate” (Wall, 1962).
  • Endorphin (natural pain killer) levels increase after 20-30 min of immersion (Frye, 2004).
  • A 2000 study in the UK (Balaskis, 2004, p51) determined waterbirth is an effective method of pain relief. A dramatic reduction of narcotic pain meds was seen (eg 3% vs 60% for pethidine).
  • As with any position changes or new environments, it’s important to wait several contractions or ½ hr before determining the full effect of water on pain.

Baby Benefits:

Gentle transition.  Babies born in water are more settled, alert, and less stressed.

Birth in Water

The mother or father can bring the baby out of the water over 5-7 seconds.  Over-stimulation should be avoided so baby doesn’t gasp for breath while submerged.  If the cord is pulsing then the baby’s getting oxygenated blood.  Midwives report that water-born babies are calmer and slower to transition so might not appear to breath as quickly as land-babies.  First breaths are often smaller and slower.

Special Conditions that Benefit from Water Birth

It’s essential to find a practitioner comfortable and experienced with these conditions in water.  Enning (2004) lists the following as benefiting from waterbirth:

  • Pre-eclampsia- darkness, privacy, water at proper temperature lower blood pressure.
  • VBAC (vaginal birth after Caesarean) – decreased risk of uterine rupture.
  • Big baby, small mama (rare) – waterbirth practices and dynamics create optimal space in pelvis.
  • Malpositioned baby – water allows baby to maneuver in a manner to allow easier birth of head.

When to Get In

Michel Odent (1997) reports that contractions can be boosted or inhibited, depending on how long a woman spends in water.  There’s an initial decrease in stress hormones upon immersion, resulting in higher oxytocin levels and hence stronger contractions.  After a couple of hours the effects can wear off and labour may slow.  The “oxytocin wave” usually carries through to birth if a woman gets in during active labour.  Women who get in earlier often have to get out before transition due to labour slowing.  Birth attendants around the world report the same thing.  Eriksson et al (1997) found that women who entered the pool early had more interventions and longer labour than those who entered after 5cm.  Although laboring upright on land often re-establishes labour, oxytocin augmentation may be required.

When to Get Out

Medical reasons to assist mother out of the tub include significant labour slows or stalls, non-reassuring vital signs in mother or baby, postpartum hemorrhage, suturing, and anytime the baby must be born quickly.  It’s important to rehearse a plan and be prepared for a necessary or quick exit from the pool.

When to get out after a healthy birth is a contentious issue.  Getting out in first hour may interrupt sacred bonding time or decrease maximum oxytocin released during this stage.  However, current recommendations are that mother leave (with the cord intact) to birth the placenta.  In any case, someone must hold baby as mother leaves the pool in case of dizziness, light-headedness, slipping or difficulty getting mother out of pool.  Besides, wet babies are very slippery.

Ideal Temperatures for Waterbirth

The general rule in North America is 32-36C for labour and 36-37.5C for delivery (Wheatly, 2008; Balaskis, 2004).  Cornelia Enning has done extensive research on waterbirth physiology.  She generally recommends lower temperatures and different temperatures for different stages, positions and multiple births (Frye, 2004, p471-3). She found that babies born in cooler water are more active and vigorous.  If a woman feels the need to be in a tub for early labour (pain management etc) the pool should be 35-37C, although Enning’s findings agree with Odent (1997) that submersion in early labour can slow or stall the process.

In 2002 Geissbeuhler et al. conducted research where women chose their water temperature and time in the pool.  Despite ranges of 23-38.9C and 28-364 minutes, maternal and infant body temperatures all stayed within normal range.  Women intuitively know what’s best for them and their babies!

Depth of Water

When kneeling, the water should cover mother’s belly, just below her breasts.  When sitting the water covers her breasts but not shoulders to allow heat-loss.  When holding her baby she can choose a position to keep the head out of water but body submerged enough to keep warm.

Equipment for Water Birth

Waterbirth equipment includes extra towels, a kettle to boil water, equipment to maintain pool, a floating thermometer, and strainer & container (for debris in pool).  See Homebirth Supplies for a detailed list.

Possible Risks / Common Fears about Water-Birth

Infant inhaling pool water is the number one risk and fear.  An innate, physiological and powerful “Dive Reflex” protects healthy fetuses from inhaling water (Johnson, 1996).   However if a baby is deprived of oxygen the dive reflex may be over-ridden in favour of gasping for air immediately upon birth.  Oxygen-deprived babies almost always show signs of stress during labour such as meconium or heart-rate abnormalities.  In this case birth should take place on land.  With careful monitoring the risk of a stressed baby aspirating water is decreased.  A baby with reassuring heart tones all the way through labour is highly unlikely to develop last minute hypoxia; however it’s a rare possibility.

Normal newborn breathing pattern:

  • Intact cord and placenta help inhibit breathing due to high levels of prostaglandin.  If cord is clamped or cut while baby’s under water it can initiate breathing under water.
  • Babies won’t breathe in body temperature water.  The main breathing stimulant is exposure of cheeks, nose and mouth to air at least 1° cooler than body temperature.
  • Newborn babies may be stimulated to breath with too much handling.
  • When baby tastes fluids the larynx (in throat) automatically closes.  This also prevents babies from aspirating breast milk during feeding.

Assessment of mother & baby may be more difficult.  However, birth attendants who are educated and practiced in water-birth can do accurate assessments.  If unsure the mother is asked to leave the tub.

Dehydration of mother is a risk of waterbirth but can easily be prevented by diligent birth-attendants who hydrate mom and maintain water temperature.

Water embolism:  Some believe it’s possible for water to enter mother’s bloodstream via the uterine placental site.  Others believe it’s impossible as the cervix is swollen and closes after birth, which prevents water from entering.  Balaskis (2004) states there are no known reports.

Cord snapping:  Gilbert (1999) cited a possible link to waterbirth and increased cord-snapping but there is no significant evidence to support this.  In any birth the cord and mama-baby should be treated in a way to minimize or eliminate cord-tension.  Incidence and treatment is the same for water or land.

Polycythaemia (too many red blood cells) has been suggested as a risk (Austin, 1997) but there’s no evidence that water caused it.  Practitioners don’t seem to consider this a risk (Balaskis, 2004).

Contamination of pool water:  Floating debris is removed by birth attendants.  If water gets too messy, mother will leave the pool so it can be drained, cleaned and refilled.

Infection transmission:  Parents’ “germs” generally don’t pose a threat to baby.  Infection rates are very low (Balaskis, 2004).  If baby’s father is in the pool there are no hygiene concerns, as he and mother share the same bacterial environment that baby will share.  Mother’s friendly bacteria are protective to baby.

Conclusion

Waterbirth provides a wonderful and gentle birth experience for both mother and baby.  Often shorter labours with fewer complications are seen.  This in turn leads to a better experience for dads.  Mothers rate high satisfaction with waterbirth experiences, as do fathers and birth attendants.

 

References

Austin T, Bridges N et al. (1997).  Severe neonatal polycythaemia after third stage of labour under water.  The Lancet, 50, 1445-47.

Balaskis, Janet.  (2004). The waterbirth book.   London:  Thorsons.

Buckley, S.J., Dr.  (2005). Gentle birth, gentle mothering.  Brisbane:  One Moon.

Enning, Cornelia.  (2004). Lecture notes from 2004 International Waterbirth Congress, Chicago, IL.

Eriksson M, Mattsson L-A and Ladfors L. (1997). Early or late bath during first stage of labour: a randomized study of 200 women.  Midwifery, 13, 146-148.

Frye, Anne.  (2004).  Holistic midwifery: A comprehensive textbook for midwives in homebirth practice, vol 2.  Portland: Labrys.

Geissbeuhler V et al.  (2002). Waterbirth: water temperature and bathing time – mother knows best!  J Perinat Med, 30(5), 371-378.

Gilbert, Ruth E; Tookey, Pat A.  (1999). Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey.  BMJ, 319, 483-487.

Johnson, Paul.  (1996). Birth under water – To breathe or not to breathe.  BJOG: An International Journal of Obstetrics & Gynaecology.  103(3), vii-vii.

Odent, M., Dr.  (1997). Can water immersion stop labour?  Journal of Nurse-Midwifery,  42(5).

Wall P.D., Melzack R. (1962). On nature of cutaneous sensory mechanisms.  Brain, 85, 331.

Wheatley, Lainna.  (2008). Midwife’s Assistant Orientation class notes.  SLC: Midwives College of Utah.