I am betting THAT got your attention! As labor doulas, as childbirth educators, we spend much of our time helping clients who have asked us to help them avoid routine medical intervention. Not every couple who attends childbirth classes or hires a doula wants an unmedicated birth, but it has been my experience that most who go to the trouble and expense of doing so wish to be judicious in their use of medical intervention and medications for pain. Books abound on the subject and, as birth professionals, we are familiar with the arguments and evidence for the cautious application of interventions.
In our roles as birth workers, we must consider that every woman who ever approaches us for guidance as she prepares for her birth will have a different set of standards for her ideal birth. Every woman who ever approaches us will also come to us with a different paradigm about birth and sexuality and her own power and vulnerability as a woman. It is our job to recognize and accept where she is and to provide her with the information she needs to get where she wants to go, to help her prepare to achieve her birth goals.
The first lesson of labor (and of life) is that we are not in control. We make our plans, then play the hand we are dealt. We can teach our clients that they and their babies deserve the birth of their dreams. We can help prepare them to select an appropriate birth place, a supportive care provider, and help them to negotiate and prepare a birth plan that works in favor of achieving their goals. We can also remind them that while the active, thoughtful, conscious planning of their births is important, we cannot control the outcome of birth. Parents can and should make their best plans, then they should prepare to play the hand they are dealt on their birth days.
We should be aware that women who are planning out of hospital births are at particular risk in terms of their thinking regarding medical intervention. These women have, in most cases, completely embraced the idea of an unmedicated birth. If or when a transport becomes necessary, the woman must shift her thinking, alter her vision of her birth and submit herself to a set of circumstances she often worked hard to avoid. We serve our clients well if we have helped them face the possibility of unforeseen and unwanted circumstances. We should encourage them to not only face these possibilities, but also equip them for how to navigate these waters just in case she finds herself there. Sometimes when women are facing a transport, they can feel such a blow of defeat that they completely acquiesce to any and all interventions. She has lost her home birth, her thought process may go, she might as well just get the cesarean. Emergent transports will likely not afford the luxury of time for discussion. This conversation would be inappropriate if there was any indicator that a mother or baby were in danger that might necessitate a cesarean. However, most transports will be slow transports and a brief conversation can go a long way to help our client get her head around the change in her circumstances. In the midst of transport, it can be helpful to say aloud to this client:
“I know that this isn’t what you wanted. I’m so sorry this is happening. I feel so proud of the work you’ve done so far in this labor. It is ok to be angry about this, cry and scream and break something. When we get to the hospital, you are going to dry your tears and take a deep breath. There is still work to be done to get your baby out and we are all going to be here to help you do it. You can do this. You are doing it.”
Childbirth educators and doulas are in unique positions to encourage our clients to explore their views of interventions, help them prepare for decision making with the B.R.A.I.N. decision making tool and explain the value of exhausting less intrusive options before utilizing major interventions.
Here’s the truth about medical intervention during labor: there is no intervention that can be done to or for a woman in labor at a hospital that might not, at some point, during someone’s labor, be necessary. Many clients will just want to avoid interventions that are not necessary for them. If we teach our clients that interventions are inherently bad, we run the risk that if a snag occurs during their birth, any deviation from their plan, they may be completely unable to cope with the idea that sometimes interventions are necessary. Women who are trained in the intervention-as-devil line of thought may feel like failures if they opt for an epidural or if other interventions become necessary during their labors. The mindset that interventions are ALWAYS negative perpetuates women’s feelings of failure and certainly does not serve women well. While the evidence is clear that our current system overuses interventions, it is important that we recognize, and help our clients recognize, that no intervention is the devil. All medical interventions are just tools, nothing more, nothing less. We can buy them if we need them and leave them if we don’t. All interventions, including pain medication, are tools and can be of great therapeutic benefit when used appropriately.
It is important to see that our clients are as prepared as they wish to be in the B.R.A. portions of the B.R.A.I.N. decision making acronym. The acronym B.R.A.I.N. reminds a laboring woman to consider the (B)enefits, (R)isks, and (A)lternatives to interventions being offered, then to consult her (I)nstinct/(I)ntuition, then to ask if the intervention is necessary (N)ow.
Most, though not all, of our clients will want to know the benefits, risks and alternatives to routine medical intervention. Include the information in childbirth classes. Recommend classes and/or reading to doula clients or offer information in prenatal appointments. Help your client prepare questions for her care provider, then help her use the answers she gets to prepare a workable birth plan. If the time comes during labor when it is necessary to buy an intervention, to employ a tool, your well-informed client is much more prepared to make a decision she will not later regret.
Take a few minutes in childbirth classes or at prenatal meetings with clients to help your clients face the possibility of interventions. It is useful to encourage clients to think in terms of using small guns before big guns. This means not only trying all of the techniques that doulas employ to progress labor, for example, movement and positioning. It also means using less invasive interventions before trying more invasive ones. Each woman will have to decide for herself which are the bigger guns in any given situation.
Pitocin, for example, has developed quite a reputation for being a bad thing. People want to avoid it at all costs. When I encounter a client whose stance is “no Pitocin under any circumstances,” I see an opportunity to help her explore her paradigm of Pitocin. I paint for her a scenario and invite her to think through a response. I use the same scenario in childbirth classes to start couples thinking in terms of small guns vs. big guns. “What if your water is broken and we have tried positioning and movement? There is a limited amount of time to get the baby out and the contractions you are having are not opening the cervix. Do you want Pitocin or a cesarean section to get the baby out?” The situation highlights a positive use of Pitocin, one that helps clients see it as a small gun and useful tool, rather than an evil big gun.
For some clients, the use of an epidural might seem like failure, something to be avoided at all costs. Work with your clients to clarify their thoughts. “What if the fork in the road is this: you’ve been laboring for hours and you just cannot go on. Do you want an epidural or a cesarean?” Our personal answer to the question is irrelevant. Each client’s answer is the one that counts for her. She gets to decide which is bigger guns, the epidural or the cesarean. It is our job to support her in her decision.
Using the small guns vs big guns approach helps clients clarify their values and streamlines for them the decision-making process. It also goes a long way toward helping women not regret a decision later made on the fly during the stressful process of labor. If clients know that they have exhausted every preferable option at their disposal, if they know they have done all they can do, they are less likely to doubt or regret their decision later when they have had time to process their experience.
None of this is to say that there will not be grief from traumatic birth. Each woman experiences trauma differently. A transport, even if necessary, can be traumatic. Getting an epidural can be traumatic. Certainly, the woman who experiences obstetric violence and/or a cesarean will require much time to grieve and process her experience. We can acknowledge the feelings of sadness, even as we help her prepare for the next step. Try simple statements that hold space for the feelings and help to move forward to keeping her head in the game of laboring to have her baby. “I am so sorry this is happening. You and I are going to have lots of time later to process all the feelings you must be having.” If there is time, give her a moment . “Do you need a moment alone with your partner or may I be with you to cry about this?” After making space for the feelings, acknowledge and help her move to the next step. “You are so brave and strong to make this decision you so wanted to avoid . I feel so proud of the good decisions you are making. We are all going to be here to help you get this baby out and you are going to feel so much better when she is in your arms.”
The idea of interventions as tools, a working knowledge of the benefits/risks of and alternatives to interventions, and the approach of small guns before big guns work together to help our clients make decisions that are right for them. These concepts serve even, and especially, when the circumstances of their births are not exactly how they envisioned. Let’s encourage our clients to make the very best plans, plans for the birth of their dreams. Let’s also prepare them to know what to do if the hand they are dealt requires that they step off the path they envisioned. Birth does not have to be “perfect” to be empowering and positive. Positive and empowering can be bought with being prepared and confident of the ability to make the right choices for themselves.
CLD, CAPPA FACULTY
Debbie began learning about birth in 1996 when she became involved in the local Houston birthing community. She believes that it is the most precious and sacred of honors to be invited to care for a woman and her family during their birthing time. Debbie is a doula in private practice and has been privileged to attend over 350 births in many homes and birth centers and over 30 hospitals. Her work has taken her places she never expected to go, including becoming a radio show host! Debbie regularly guest hosts Whole Mother on the local public radio station. Debbie is proud to be the mother of two amazing formerly breastfed and home-schooled young adults. To reach her and register for upcoming trainings, please visit www.debbiehulldoula.com or email her at firstname.lastname@example.org.