The Trauma of a Doula who Witnesses Abuse in L&D

I wish I would never have to write this blog post, but I am afraid it is the only way for me to heal my own trauma. I witnessed abuse in the L&D room. I felt helpless. I felt I had to remain silent in order to stay in the room. This experience made me think of all my doula sisters who are witnessing abusive experiences all over the world.  They must remain silent in order to stay in the room. I want to be the gatekeeper in L&D. I am like the news reporters who report crimes against humanity and wake the world up to take action.

Can birth support become a traumatic experience for doulas?

Verbal abuse in L&D: threatening, scolding, ridiculing, shaming, coercing, manipulating, mocking, dismissing…

The terms Vicarious traumatization (VT), Secondary Traumatic Stress (STS) and Compassion Fatigue, are professional terms describing the trauma of caregivers. The trauma results from empathetic engagement with traumatized clients and their reports of traumatic experiences. Even this term cannot describe the trauma of the doula who witnessed her birth client being abused. I did not hear the traumatic birth story, I was present when it happened.

I want to stress the fact that this childbirth could have been considered a beautiful, healthy and positive birth process if it weren’t for the abusive behavior of the doctor. In order to convince you of that, I ask that you read the birth story below twice- on the first reading, read only the black text; on the second, read the parts that are in green italic letters as well. The birth story is at the bottom of this post.

I am not the first one to report abusive behavior in L&D. As part of my healing process, I searched for articles about abusive expressions in L&D and found them in the two languages that I speak and read: English and Hebrew. A few months ago, an article came out in one of the most prestigious Israeli newspapers describing the horror and abuse of Israeli birth givers experience in L&D.

We (doulas, patients, L&D nurses) tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

The topic has been researched and studied

I discovered this article: Abuse in Hospital-Based Birth Settings, by Susan Hodges, MS, to be very helpful in achieving my goal – defining the trauma of the doula who witnesses abuse.  Hodges describes the expressions of labor and delivery abuse as well as the dilemma of the abused patient: Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge—behaviors that undermine the recipient’s self-esteem while enhancing the abuser’s sense of power, typical of bullying. Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be “compliant” with medical directives, these behaviors are seldom recognized and interpreted as abuse. Furthermore, staff and doctors are the authorities in the hospital, while the pregnant and laboring woman is merely a “patient.” Such a huge power imbalance allows, even encourages, bullying and abuse. We tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

By using the word ‘we’ in the last sentence Hodges implies that patients and doulas, or other witnesses, are in the same position – feeling helpless and rationalizing this behavior as ‘poor bedside manners’ – which we tend to be more forgiving towards, as a society. How many times did you hear the sentence, “He has poor bedside manners, but he is a great doctor”.

I believe that that the doula position is different in regard to an abusive environment in two aspects:

  1. Doulas know better than their clients on what to expect: While the doula and the expectant couple can both equally recognize rude behaviors such as “ridiculing, shaming, coercing, yelling, belittling, mocking, dismissing…,” the doula is more knowledgeable and experienced in the field of birth support and is far more equipped to recognize threatening, manipulation, and lying.  Identifying these in Labor and Delivery will require basic knowledge of the field terminology, ‘evidence-based care’, and a basic understanding of causality in childbirth. This means that the doula can detect and identify abusive behavior that her clients may perceive as an act of care. Hodges points out the need to educate birth givers in order to reach an informed consent:Women who are well-informed and ready to ask questions about procedures, treatments, and interventions during labor can address some deficiencies of “informed consent” and not be hoodwinked into unnecessary interventions.“ However, this kind of education breaks the rapport and trust between birth givers and representatives of the medical system. This situation is described by Christine Morton as the doulas’ advocacy dilemma in her book ‘Birth Ambassadors’, and there is a general agreement among doula certifying organizations doulas should avoid initiating a tug-of-war in L&D.  Additionally, this type of education seems to work prenatally, but is flying out the window when birthing individuals are overwhelmed with fear.

A doula who speaks-up is taking the risk of becoming an unacceptable or unwelcomed at this facility in the future

  1. Doulas lack the ability to file a complaint or take any affirmative action: Several organizations, such as CIMS, LAMAZE, and Citizens for Midwifery, encourage birth givers, who suffered abuse in L&D, to file a complaint following the birth. According to Hodges, this action is not only with the purpose of reducing the expressions of abuse in L&D, but instead is perceived as an act of empowerment. “Filing complaints alone will not solve the problem. However, women, I’ve spoken with who did so felt empowered, and it helped them acknowledge to themselves that they had been mistreated and were not at fault. Well, here lies a big difference between the patient and the doula. Doulas remain silent.  A doula who shares her negative experience with a caregiver or with hospital staff is taking the risk of becoming an unwelcomed persona in this facility.  We are lucky to have our doula support circles, and we can always cry on our peers’ shoulders and get their support, but this is equivalent to the birth giver sharing her trauma with a friend, and this might not be enough for true healing and empowerment.

Please read the story twice

Now that I’ve shared some general insight about abusive behavior in L&D, here is the birth story that I promised to share with you. For your own benefit, please read twice as previously requested.

My client, Beverly, woke up at 4 am in a puddle. Her first labor began with a rupture, and her contractions began shortly after. By 7  am her contractions were around 50 seconds long and about 5 minutes apart. At 10 am, her contractions intensified and occurred every 3 minutes for about 1 minute at a time. At that point, Bev noticed that she was bleeding and decided to meet me at the hospital.  Upon arrival at the hospital, she was vaginally checked and measured to be 4-5 cm dilated and 90% effaced, and after a 30 minute EFM, we went to the shower. Bev was breathing beautifully and handling her birth with grace and confidence. Her OB was out of town, and the on-call OB from his group showed up and went into the shower to listen to her lungs. After the OB visit, Bev’s partner came out of the shower and shared that the doctor was commenting on the couple’s request to delay the cord clamping, by saying that he can wait only 90 seconds, as too long of a wait can lead to disasters. He shared an article he has just read about the baby’s leg amputation due to a cord clamping delay. I went back to support Bev in the shower, and she shared her disappointment that her OB was not the one to see her through her birth. After a long hour in the shower, Bev felt some pressure towards her anus and was asked to come out and be checked. She was 6-7 cm, 100% effaced, baby in a station (-2).  It felt for her like the right time to get the epidural that she has planned on taking. At 4pm, the nurse started the drip of fluids. Coping with the contractions in the room Bev was convinced that taking an epidural is the right thing for her. She asked for a low dose epidural, but the anesthesiologist has said that preference is, to begin with, a good dose and then slowly lower it. Following the administration of epidural, Beverly’s contractions have totally stopped, her blood pressure went deeply low, and the fetal monitor showed a 4-minute deceleration, which was controlled and recovered with a change of position and oxygen. She had no sensation nor the ability to control her legs. While the nurse and the anesthesiologist were mainly occupied with recovering the low blood pressure and the baby’s FHR, I was concerned with the lack of contractions. I thought it will be wise to prepare my clients for the possibility of administrating Pitocin, reminding them that it is one of the possible side effects of epidural. After 3 hours wait, with no sign of contractions, The OB came into the room and began explaining to the couple that as for now, a process of deterioration of the baby’s brain has already begun. The OB further explained that if they do not manage the birth and bring it to an end than this deterioration can become brain damage. (I am sharing the nuggets of it, as he rambled on and on for a good 10 minutes, sharing ‘studies’ and medical schools ‘All in favor of the couple making an informed decision’. ) When the couple asked for a few minutes to think about all that they have heard, the OB looked me in the eyes and said: ”Just for you to know, under the law of California, any medical advice is considered practicing medicine and you will be in big trouble”.  The couple decided to follow the OB’s suggestion, who has inserted the IUPC and began Pitocin. Following the administration of Pitocin. Bev’s contractions have recovered; by 8 pm she was fully dilated, with the baby still in (-2). A dose of antibiotics was given to the birth giver due to maternal fever and the long rapture. By 10 pm, with the baby in (-1), she began to push. When the baby came down to (+1) Bev was able to feel the pressure building, and she pushed strongly, making progress with each contraction. The nurses changed shifts and we had a new, refreshed and very supportive nurse in the room. As the baby descended, there were a few more declarations that recovered after the contractions were over. The nurse kept encouraging and complimenting Bev for her effective pushing, and then the OB came again to the room and began talking to the partner. In his words, he said, “I know you do not like it when I bring things ahead of time, but I think it is important for you to make an informed decision, therefore I want to talk to you about choosing between forceps and vacuum”. Then he stopped because Bev felt the urge being built and we all attended to her as she pushed, the husband is next to her head and counting, the nurse at her perineum and I stood by her side supporting her leg. The contraction is over and the OB continues talking: ” I personally prefer the forceps, but it is a matter of medical schools, as most doctors these days will use the vacuum…..” and he stops again as Bev is asking for our attention and is pushing like a lioness, I swear. As he went out of the room, leaving the partner to make his decision, the partner asked me what was going on. He felt like one of us is lying to him, not telling the truth.  How can it be that the nurse and the doula are being all excited about the progress, and the OB is asking him to choose between the vacuum and the forceps? The nurse and I tried to reassure him that there will be no need for him to choose.  He was so terrorized and said:” I know the vacuum to be safer for the baby, but I’m afraid to choose against his preference, he might get really angry and decide to end it now with a cesarean”. In order to lead him back to his logical thinking, I began asking questions: ”What do you know about vacuum and forceps”? And then asking the nurse: “Percentage-wise, what would you say is used more here in the hospital?” The nurse was reassuring the dad that he needs to choose based on what he feels more comfortable with.  This coaching conversation took place between moms pushes. I went ahead asking the nurse: “Is there a medical reason that you are familiar with to end this birth with a cesarean now?”, and we both reassured the dad again and again, while all along the mother kept pushing, and — here comes the head!  The OB was called to the room and began dressing. While it was clear that in the next contraction the head was going to show up, he said “Well, because you were waiting so long since the water broke, and as I explained the deterioration has begun hours ago, and there is already maternal fever, your baby will go to the NICU and will stay there for two days for special care”. The NICU team arrived and a few minutes later we heard the baby crying his lungs out. The neonate doctor said: ”Why was I called? This baby boy is so strong, here mama” and she puts the baby on the mother’s chestBev’s healthy and strong baby boy was born at 12:30 am, and he nursed right away. The couple had two beautiful hours of bonding with the baby.

Does Birth Activism Lead Expectant Individuals to Demand Better Maternal Care?

Recently I watched the movie ‘Trial of Labor’, and listened to the stories of three women who wished for a VBAC (Vaginal Birth After Cesarean). It made doubt the approach we, birth activists, take in our efforts to improve maternal care. Especially our continuous attempts to educate and empower expectant individuals by pointing out the flaws of the medical system and its representatives.

What did birth activism look like in the 90s?

I gave birth to my oldest child in 1995. I often say that she was my muse since my first pregnancy and birth experience led me to pursue a career in the field of birth support. I was lucky to go through this journey in the 1990s, as it seems that these years offered women a wealth of information about natural childbirth: Barbara Harper first published Gentle Birth Choices in 1994, the same exact year that Michel Odent published his book – Birth Reborn. Janet Balaskas published Active Birth in 1992, and Marshal H. Klaus published Mothering the Mother in 1993. Henci Goer closed the 1990s by publishing The Thinking Woman’s Guide to a Better Birth in 1999. All of these authors were, and still, are my teachers and mentors, not to mention idols.

Continue reading

Webinar: Coaching Your Client through the Dilemma of Epidural

How to Coach Your Birth Client through the Dilemma of Epidural- Before, During and After Childbirth

This one hour webinar first aired in celebration of World Doula Week, March 2015.  In light of the high percentage of birthing moms who end up using epidural in their childbirth, it is time doulas learn to conduct the epidural conversation. This conversation should take place prenatally. It is also important for every doula to know how to coach her clients through moments of doubt and crisis in order to avoid epidural during birth. However, when the mother exhausted her ability to cope with labor pain, it’s time for her doula to make a shift in her coaching strategy. Learn how to best coach and support your client’s progress after the administration of epidural, and how to facilitate acceptance and clarity about the mother’s decision to use epidural, during the postpartum visit.

Testimonial: “I absolutely LOVED your “Epidural” webinar!  Thank you, very much!  There were amazing tips I’ll want to use… Half of my clients had epidurals, and I’m afraid that I didn’t do everything for them that I could have.  After the epidurals were administered, I wasn’t much use to them, and I think my closure visits were weak.  At any rate:  THANK YOU, VERY MUCH!  In the doula spirit, Britt Hatch.

Visit our store here to purchase the webinar

Here is what you can expect to learn when joining me for this webinar:  coaching with epidural

1. Learn how to recognize and create the opening moments for a coaching conversation which will evoke a change.

2. Learn how to structure your coaching conversation, following the GROW model of coaching.

3. Study potential scenarios in which the dilemma of epidural might show up, and learn how to tap on your Client’s motivation and commitment in order to lead her through them,

4. Become familiar with the different domains of coaching for childbirth – the prenatal domain, the hands-on coaching and the domain of closure.

5. Learn how to integrate the BRAIN model of medical interventions into your prenatal coaching.

6. Don’t miss my very own coaching technique around pain, a complete refute of the horror myth of ’24 hours of pain’ by using 3rd-grade math 🙂

In addition to the information regarding epidural, you will learn the basic terminology and principles of coaching, which you can integrate in your doula practice.

Accountability Vs. Responsibility in Childbirth

This post is dedicated to my recent birth client Greta – as committed and accountable of a mom can be. (Shared with her permission after changing her name)

Let me begin by sharing that one of the last births I have attended left me with a heavy heart. I have coached my client Greta for about 3 months toward achieving her goal: a VBAC for her second birth. During our prenatal coaching sessions, I came to respect her as one of the most committed, mindful, and accountable birth clients that I have had the honor of working with. I was looking forward to cheering her on during delivery, but we never got there. In fact, I did not even get to coach her through her birth.

As a birth professional, I trust you to know how hard it is nowadays to accomplish a VBAC. Greta was well aware of the challenge but remained committed to her wish for a vaginal birth. Her commitment was reflected in the long list of actions that she took in order to accomplish her goal:

  1. Greta’s first step was to establish her support group; she received support from her doctor, husband, family of origin, and me, as her birth coach.
  2. Greta is a working mom in the high-tech industry of Silicon Valley. Nevertheless, she was committed to making lifestyle changes in order to prepare her mind and body for the birth. She took prenatal yoga classes, swam until her 8th month, used her lunch break to hike every day, and watched her diet carefully. She also signed up for a hypnobirthing class and practiced the scripts.
  3. From the very beginning of our coaching relationship, it was clear that Greta was very knowledgeable about  childbirth and was in constant  search of more knowledge. In fact, she would take the lead in our discussions in regards to any type of remedy or alternative medicine support; she initiated emails and discussions about evening primrose oil, aromatic oils for birth, perineal massage, homeopathic tinctures, etc.
  4. During the last three months of her pregnancy, Greta and I met every other week for a prenatal coaching session. During these meetings, we worked on leaving her first birth experience behind and practicing forgiveness and acceptance. We practiced breath work and relaxations and wrote her an affirmation to attract the birth experience she wished for. We exchanged knowledge and distinguished truth from myth about childbirth. We wrote a birth plan, practiced positions, and addressed her fears and doubts that she might not be successful in her efforts to have a VBAC. It is the last point, coaching my client through the uncertainty of the outcome; pushing through one’s doubts and fears about not giving birth the way one wished for, that brought me to the write this post.

With the high rates of cesareans nowadays and the fact that we were having a TOLAC (Trial of Labor After Cesarean), we both knew what Greta was up against. So how can one persevere against the odds? It is almost as if no expectant mom these days can avoid preparing herself for a cesarean meanwhile preparing for her vaginal birth, and even more so, a mother who has already given birth once in a cesarean birth. So how do we coach mothers around these fears and help them push away the doubts? How do we not let these get in the way?

From a coaching point of view, we are talking about accountability Vs. responsibility. The major difference between these two concepts, and this is true in every field of coaching, is in the attachment to the outcome of our efforts. Accountability is the obligation of the individual to account for one’s actions, and accept the responsibility for them. Responsibility is the obligation of the individual to perform or complete a task. Do you see the difference? Being responsible means that you are accountable for the outcomes whereas being accountable means that you are responsible for the actions you take in the process of working toward achieving your goal, with no attachment to the outcome.

In childbirth, we can only be accountable for the process, for the actions we take towards a conscious and mindful birth. There are so many agents involved in birth; our physiology, our anatomy, the baby, the birth environment, our support group, the medical staff’s training and their reading of the situation, our stamina, our mental and emotional state before and during the birth, the list goes on. The bottom line is – doulas and birthing moms cannot be responsible for the outcome of a birth, only accountable for the actions taken.

As I coached Greta through her doubts, I chose to share these concepts and the difference between them in order to help her push through the uncertainty and leave her first birth experience in the past. During the prenatal coaching, it became clear that she was still angry with herself for not being accountable for her first birth. In fact, only while preparing for her VBAC, she acquired closure for her first birth and was able to generate a coherent and clear memory of what had happened the first time around. I can clearly remember three different opportunities where I brought the difference between accountability versus responsibility. I used it during prenatal coaching in order not to drag her past experience into the present by acknowledging the higher level of accountability that Greta was demonstrating now. I also used it in order to push through the fear of the possibility of a repeat cesarean by pointing out the inevitable of  what we can’t control.

healingGoing back to my heavy heart, I assume you guessed that the birth ended with another cesarean; it was a pretty traumatic one. Greta texted me around 11pm on Sunday night about a pain in the lower abdomen waking her from her sleep and that she thought her water broke. There were no contractions at that point. After 10 minutes or so, I got another text saying that the contractions had begun, strong and steady and 5 minutes apart, each lasting for a minute or more. I texted back that I was getting ready and would soon be on my way to her. Ten minutes later, when I had just gotten into my car, I received another text from the dad this time, telling me that Greta was shivering and that the contractions were 3 minutes apart, lasting almost 2 minutes each. The intensity of her state prompted me to call and ask them to meet me at the hospital. I arrived there first and was still thinking, “what if she is at the very beginning and will be upset with me for not supporting her in laboring at home longer.” After all, our coaching agreement was to labor at home for as long as possible.

Their car rushed into the hospital’s parking lot. Greta’s husband jumped out and so did her mom. Greta could hardly stand, could not breath, and was in extreme pain. We entered L&D with Greta in the wheelchair. The nurse led us to the observation room and monitored the baby’s heartbeat. Five minutes later, I was left there all alone as my client was rushed to an emergency cesarean due to a very low fetal heart rate. During these five minutes, the medical staff commenced their fervent evaluation at the midst of an emergency –  vaginal exam, internal monitor for verification, declared code C, inserted IVs, withdrew blood, verified allergies, gave verbal explanations, and established consent.

As a doula, I often hear the following saying “what matters is that you have a healthy baby and healthy mom.” We use this saying to comfort mothers that did not have the birth experience they wished for. While this is the absolute truth, it is beside the point. It addresses the outcome of the pregnancy and not the birth experience. Therefore, it is not the best coaching strategy to resolve any bad feelings that the mothers might have regarding her birth. The mother was not only accountable for having a healthy baby but also for having a vaginal and healthy delivery. I find that the ‘Accountability Vs. Responsibility’ coaching discussion is a good strategy that can support both the mother and her doula.   I know it helped me in my healing process, along with a local online doula support group (Yes, doulas are online at 2 in the morning, thanks sisters!)

When I got back home I sat down to practice breathing and meditate. The morning came, and I decided to make Greta a card. I searched on the internet and found the image shown above. I actually made two cards, one for her and one for me. I went back to the hospital around 10 am. Greta hugged me and asked how I was. I replied by asking how she was doing,  but  she kept reassuring me that she is fine, that she has no remorse, and that she is in full acceptance of the circumstances. “This must have been really hard for you, Neri; emotionally, your work is so hard,”she said.  For a moment I was not sure that I had made the card for her, it might have been for my own well-being. Greta felt that she did everything that was in her power to have a healthy childbirth. Even though this time  it was an emergency cesarean under general anesthesia, she shared that she was more at ease with it this time because she felt mindful and accountable, and it empowered her to accept the inevitable. Her words helped me be grateful for taking part in this birth and being there to guide her with my coaching skills and experience.

If you enjoy reading this post , and you find this terminology and coaching strategy valuable to your practice,  please consider studying The Complete Coaching Tools Kit for Doulas,

Hey Doula, Can You Handle My Husband?

Were you ever hired by an expectant mom to “handle her husband”?

In my sixteen years of practice, I have had a few clients who hired me in order to do just that – handle their husbands. There could be various different explanations that come along with this request, such as:  “I do not want him in the room at all, but I don’t want to hurt his feelings, so please make sure he is busy, give him tasks” or “My husband is taking over any situation, I can’t have him take over my birth”, as well as “He thinks he can take it, but I know him, he can’t, so I need you to be his doula and keep him calm”.

From a coaching perspective, doulas are in the business of group coaching. If it is more than one, it’s a group!

Coincidentally enough, my doula students and I have had more than a few encounters with the request to ‘handle husbands’ lately, and I believe many other doulas might have too.  Couples’ dynamics can be challenging in childbirth; it can interfere with our doula support and can have an impact on the couple’s level of satisfaction from their birth experience. By fully understanding the situation at hand and acquiring coaching tools to deal with it, doulas can be ready for the challenge, and reduce its impact on their support, resulting in higher levels of satisfaction for the couple.

From a coaching perspective, doulas are in the business of group coaching. If it is more than one, it is a group, and a couple is definitely a group. Doulas are trained to focus on the mom’s needs, their feelings and physical comfort, but nevertheless we cannot ignore the dad, nor can we team up with the mother and “handle him”.It is not healthy for us and it’s harming our clients.

Can we really manipulate the birth partner and ignore his emotional needs in the service of the birth giver?

We cannot ignore the dad, nor can we team up with the birth giver and “handle the partner”. It is unhealthy for us and for our clients

For the purpose of handing doulas the coaching tools for dealing with this challenge, I want to share an actual case study, with the permission of my doula student.  A couple of months ago my student met with her second client, and was asked by the mother to watch” him during labor and redirect him, “take him away” if he gets to be too much in my way.” (This is taken directly from the student’s notes). My student agreed to her client’s request, believing that she was doing her good, and here is what she wrote in her supervision report: “When faced with this request, I suggested to [mom] that we come up with a secret sign that would let me know to redirect [dad]”.

During our supervision session, following her meeting with the client, I asked her how she thought this agreement served the mother. I pointed out to her that from a coaching perspective, our role is to empower the mother to express herself, her wishes and needs, to her support group. If we do this for her, we are depriving her of opportunities to grow. Similarly, doctors wanted to rescue women from labor pains and offered them different types of pain management options. What might have begun with good intentions, ended up with mothers being disempowered during childbirth. As doulas we sometimes feel the need to rescue the mother as well, but only because we fail to perceive our clients as competent, which is one of the basic premises of coaching. Here are my student notes, concluding this supervision session: Birth Support Coaches empower birth givers to vocalize their beliefs, needs, and goals and share them with everyone involved – partners and medical caregiverspartner… that she needs space, having the birth coach do that for her is not empowering. To help the mom, the coach can suggest: would you like for the 2 of us to practice this? Can you find the words to express the fact that you need a change? The bigger the coach, the smaller the mom.  The more we do for her or take from her, the less she is empowered.”

Birth Support Coaches empower birth givers to vocalize their beliefs, needs, and goals and share them with everyone involved – partners and medical caregivers

In her following meeting with the client, my student never went back to revise her client’s request to “handle the dad”. After the birth, she texted me: “I had the feeling that my client did not want me there at all, did not want me at the birth”. As her trainer, I was concerned about that and asked her to try and explain the source of her feeling. Here is what came up: Surprisingly the dad did a very good job supporting his wife during labor, and she seemed happy with what he was doing. I was more in the background suggesting and preparing things for them. She never talked to me directly or engaged with me.”

From my perspective, the doula failed to serve the clients because she never clarified her client’s request or the motivation and beliefs the client had around this request.  The doula could have asked clarifying questions such as:

  • Can you give me some examples of what you mean by “Gets to be too much in my way”?
  • How does it look like when he is in your way?
  • How does it make you feel when he is in your way?
  • How do you react when he is in your way?
  • How do you suggest that I redirect him?
  • And the $1M question that could have evoked a change in the couple’s relationships: Would you like us to practice some ways for you to express how you feel and what you need from him?

It is not your role to provide couples’ therapy, but you can coach them gently and facilitate joined agreements in specific areas relating to the nearing birth

Instead, the doula felt that the partner did well. My poor student did not hear from this couple again, although she tried to reach out to them and facilitate closure. It was an unsuccessful experience for both the birth giver and the doula that ended p in a cesarean.

As a doula, I encourage you to pay attention to explicit and/or implicit signals that you get about the couple’s dynamics. If there are issues with their dynamics, don’t ignore them, as they will almost certainly emerge during the birth and can sabotage your efforts to help the couple achieve the positive experience they desire. It is not your role to facilitate a change in couples’ relationships; you are not a therapist. But you can coach them gently and facilitate specific agreements for the sake of healthy and positive childbirthImagine how valuable it would be for them to communicate in a respectful manner, to establish teamwork, to work out their differences, or to express their needs to one another during childbirth. This experience will leave its mark on their relationship and will empower them to create the change needed.

Here are some tools for coaching the couple around their dynamics:

  • Reflect on the explicit and/or implied message that has alerted you with questions like: ” Did I understand correctly that you are …”
  • If your impression is confirmed, ask for examples and clarifications until you are clear on the matter. “Can you give me some examples?”, “How does it looks like?” Or “How do you feel when…?”
  • Try to make the couple observe the problem. You may ask: “Do you see any problem with this? “ Or “Can you think of any impact this might have on your birth experience?”
  • Explain your position as their birth doula – focus on the fact that your role is to empower and support both of them. Explain what might be the impact of the issue, or how their dynamics might be in the way of achieving the positive birth experience they hired you for.
  • When there is agreement about the problem, we can try to facilitate a solution: “What are you guys willing to do about it?” Or “Can you think about a different way to do things for the sake of a positive childbirth experience? “
  • Create or look for opportunities for the couple to practice the new communication skill or pattern.
  • During childbirth, if there is a need, remind them of their commitment to practice new coupling skills for the sake of their childbirth experience.

Reflecting, asking strong questions, clarifying, practicing new skills, and empowering, all are coaching strategies. I am committed to enriching childbirth pros of all types – doulas, childbirth educators, prenatal yoga teachers, medical caregivers, and others, with the coaching tools and strategies. If reading this blog post inspired you to want to learn how to coach towards a healthy birth, I invite you to enroll in the Birth Support Coaching certification course

‘Birth Ambassadors’ by Christine Morton – A Book Review

Recently  I have read the wonderful book  Birth Ambassadors, which I find to be the most comprehensive and eye-opening study about doulas and birth support in North America.The book is a genuine presentation of the doula role, ways of birth embassadorspractice and training system in America from a sociological point of view. As such, it is free of any judgments about the dilemmas in the field, and views them from the perspective of sociological interests, such as professional status, the emergence of occupational niche, change agents in maternal care, community service, income level and even organizational developments. This point of view allows the author to also question, or re-open for discussion, some of the most common assumptions doulas and birthing moms ascribe to, including the benefits of doula care in terms of increasing normal births, and the doula’s agenda favoring natural birth, as well as doula advocacy in labor and delivery.

   To me, the most urgent dilemma is the one regarding doulas’ professional status. It is my understanding that this is also the core dilemma, the one that originates the others. In literature and doula guides, one cannot escape the choice of words used to name and describe this role by those who are perceived as the biggest doula advocates. Morton describes doulas for her readers using a typical definition, “Doulas are birth companions…The word doula comes from the Greek and refers to a woman who personally serves another woman.”  Neither a ‘companion’ nor a ‘doula’ implies any professional position—the latter evokes servitude rather than social change agents that come from being a mentor, a teacher, a coach or a leader. Yet, doulas are trained to believe that they can and do make change. Morton’s discussion of Klaus and Kennell’s book “Mothering the Mother,” the book that still, three  decades after their emergence in America, provides doulas with the scientific data of the benefits they bring, provides additional food for thought about how doulas are described. The title “Mothering the Mother” is another poor choice of words. As we all know, mothering is considered to be a non-professional position, and although everyone agrees that it is the hardest and most valuable work of all, mothers do not get paid for all they do.

The non-professional status of doulas in North America is reflected in the current training and certification system. Morton points out that research findings regarding doula benefits were actually based on a control group comprised of inexperienced and untrained women who sat in the delivery room and took notes.  Most doula trainings in North America are between a two-four days’ workshop. In comparison, I was trained in Israel, where doula training programs last a year and are usually affiliated with an alternative medical college and/or hospital. Trainees are required to have an internship inside Labor and Delivery.  As a sociologist, Morton points out the dilemma of doulas as being committed to providing humanistic and affordable childbirth support within the community, similar to what existed in a more tribal society before women began giving birth in hospitals, and the current situation of low status, low income and low professional standards for doulas as working women.

Morton continues to point out another motivation to maintain the non-professional status of doulas, which is closely tied with the circumstances of doulas’ historical origins. As Morton observes: “Doula care emerged as a unique response to the changing social and medical context of childbirth support in the United States” and “…the fragmentation of childbirth support [that] began with biomedical experts claiming authority over pregnant women’s health and childbirth outcomes and moving birth to the hospital…it is in this period we see the emergence of the doula as a particular, specialized role in providing non-medical support to pregnant women. “ In other words, doulas emerged in the United States as a reaction to the medicalization of birth, yet they are largely practicing within the medical system, holding to a philosophy of care and birthing model that are alien and unfamiliar in the medical paradigm. It is my assumption that doulas organizations are confusing professional status with medical status. If doulas were to claim medical authority they would not be able to practice within labor and delivery. While it is important to keep doulas as non-medical care givers, it is most important to elevate and state their professional status as coaches and care givers in the field of birth. Until then doulas are left with being viewed as community service or support figures whose motivation for their work ‘comes from the heart’.

Morton goes on to explain the controversy, facing doulas in terms of how they advocate in birth. In their current status as non-professional community service workers, how can doulas be an authoritative source for evidence-based care and empower their clients to question the medical staff and the care they provide?

I can see how some doulas and doula trainers in North America might feel challenged by this book, but I believe that this challenge is an invitation to initiate a healthy change in our occupational niche. Morton contributes to the well-being of doulas and birthing moms, by opening our eyes to the reality of birth support in North America. As a birth coach trainer, I would like to encourage all doulas to abandon the term ‘doula’ and the connotations attached to it over the past decades.  I recommend that we begin a new era of re-defining doulas as birth coaches, who can acquire coaching tools and skills, and enjoy the accreditation experienced by coaches in many other fields (such as life coaching, executive coaching etc.)  The coaching model and practice standards can resolve some of the dilemmas Morton identifies as problematic for doulas and their organizations, such as the advocacy dilemma, or practicing within the territory of doula support  without wrongly step into the medical territory, as well as coaching the mother prenatally for the performance of childbirth.  To read more about the coaching model, read my  blog post on  birth coaches vs. doulas at: https://www.birthcoachmethod.com/imagine-giving-birth-profession-doula-profession-change/.

 

 

The Misleading Concept of ‘Natural Birth’; Let’s Talk About a Healthy Vaginal Birth

The dichotomy of Natural Birth vs. Medicalized Birth had been established in the discourse about birth for the past 30 years and was accepted by both birth professionals and moms. The most obvious and urging question expectant woman is concerned with is whether or not she will take epidural or will try for a ‘Natural Birth’,  and in accordance with what she feels inclined to, she will then educate herself and prepare for her birth. She will decide on a childbirth education class and make decisions regarding her caregivers and support group for the birth based on her decision for or against taking epidural. A woman who gave birth vaginally will almost always be asked whether or not she took epidural, or in other words “did you have a natural birth’? This situation is reflected also in birth stories we read online; where we can always find statements in this spirit:  “I decided not to take epidural and try for natural birth…and here is what has happened…or “So I decided it was time for my epidural…”. What I find even more concerning, is the shower of praises and cheers that the mother who went ‘naturally’ will perceive, vs. the mother who helped herself cope with an epidural.

I think that that the concept of Natural Birth is so misleading that while preparing for this experience, a woman might find herself giving birth in a way that cannot be farther away than what nature planned for women- a rather medicalized birth. Natural Birth’ is a proposition which describes the conceptual event of some sort of birth that the speaker or listener have in mind. But what type of birth is it?  What’s on our mind when we think ‘Natural Birth’? Which pictures come to mind? Which words are associated with it?  Which scenarios do we envision and are they really ‘Natural’ for the women we know and support?

 I argue that for modern women, there is nothing natural in the process of giving birth and therefore the concept ‘natural birth’ by itself presents women with a dilemma: Giving birth is part of our nature, this is how we procreate, and yet as an occurrence in the life of modern western women, there is nothing ‘natural’ about childbirth. 

To support my argument, I checked the dictionary for the definition of ‘natural’, and found the following definition:

nat·u·ral Natural, adjective 1. Existing in or caused by nature; not made or caused by humankind. 2. Or in agreement with the character or makeup of, or circumstances surrounding, someone or something. So now let’s take the propositions of ‘Natural birth’ and read these two definitions with it: Natural birth is: 1. Natural birth is caused by nature, not made or caused by humankind. 2. Natural birth is in agreement with the character or circumstances surrounding expectant moms.

My understanding is that when we oppose ‘Natural Birth’ to ‘Medicalized Birth’, we probably mean to say or imply that this kind of birth occurs and unfolds with no humankind intervention. Well, firstly we need to recognize that this concept tells us what Natural Birth is not, and not what it is. Secondly, I want to point out the misleading implication of this definition- that when we think about something that happens naturally, with no humankind intervention, the connotations that come to mind is of something ‘simple’ or ‘effortless’, which are not at all true when it comes to giving birth. Let’s take a look at the second definition and see how it resonates with us: “Natural Birth is in agreement with the character or circumstances surrounding expectant moms”. Really? Would you agree that in terms of ‘the character of life circumstances surrounding women’ nowadays, nothing about birth is natural for the modern western woman? Do you feel the tension? There is also a conflict between the two optional meanings of the concept ‘natural ‘. I think that healthy vaginal birth, which we refer to as ‘natural birth’, has become so rare because of the dilemma that the word ‘natural’ presents. Here is the dilemma of the modern in regards to childbirth:

   “It is in my nature to give birth, yet there is nothing about birth that is natural for me”

Here are some of the reasons why childbirth can’t be or feel natural for us:

  1. Birth is unpredictable and impossible to plan for. (How many of you already planned their summer vacation? Christmas vacation?)
  2. Birth requires us to agree to be in pain, and we live in a culture that is obsessed with alleviating pain. We also lost all our coping pain techniques and skills while being born in this culture.
  3. Healthy birth is a process that lasts an average of 18 hours for first-time moms, and we live in a fast pace culture; we use instant coffee and instant pudding and order food in drive through…We like our results fast! In movies and TV sitcoms birth takes five minutes max.
  4. Being a long process, birth demands physical and emotional performance, it demands strength and stamina which the modern woman who drives her car, uses elevators, sits in a perfectly air-conditioned office, uses washing machines and dishwashers, and does not squat down the river every day, absolutely lost.
  5. Our cultural inhibitions, which are the cultural circumstances surrounding expectant moms, are in conflict with our primal and intuitive response to birth.  The progress of labor depends on the release of hormones like Oxytocin and endorphin, that are being released by the part of our brain that is called ‘primitive brain’. The primitive brain activates primitive and uncontrolled reactions and behavior like moaning and groaning,  crying and screaming, throwing up, the spontaneous motion of the body like spiraling, and other types of behavior that are not considered to be attractive or feminine, and therefore are in conflict with our cultural inhibitions.

 To summarize my argument, talking about natural birth is misleading. In a subconscious matter, which women are unaware of, thinking about ‘natural birth’ lead women to either think about something as natural as a sneeze or a yawn, something that happens spontaneously with no investment or effort and therefore needs no preparation or intentional engagement. Ironically, expectant mothers must have a thorough and deep preparation in order to give birth spontaneously, in a healthy vaginal way. For the modern woman, giving birth in the way nature planned for her is quite a performance.  It requires her to perform physically, emotionally and mentally in a way that is much different from her everyday life circumstances. And just like no one says natural marathon or natural success, nor should we talk about natural birth. 

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Practicing for an Active Birth

   I have been a childbirth educator and a birth doula for the last 14 years. During the first year of my doula practice I realized there is a difference between Knowing about birth and Being in birth. With no exception, all of my birth clients took childbirth education classes and read pregnancy and birth guides. Most of them were also committed to have a natural birth, to avoid medical interventions as much as possible, and to design their birth experience according to their belief system and their emotional and physical needs. While supporting them in birth, their knowledge did not serve them well enough. The mothers whom I have worked with were missing tools for labor.

   So I have decided to begin my support earlier than the birth, and became a childbirth educator. As an instructor I teach the Active Birth philosophy, mostly affiliated with Janet Balaskas.  In my classes I always focus on practicing  labor tools. My perception is ,that in the Google era ,couples are exposed to so much information and knowledge, that my special contribution is in teaching them the hands-on practice of being with the birth.  I have created the Practicing for an Active Birth workshop especially for clients who wanted more hands-on practice. I taught this workshop for ten years in Palo Alto. My students were raving about this class, and the local midwives were continuously recommending it to their birth clients. On November 2012 I launched the DVD “Practicing for an Active Birth; The Most Comprehensive Hands-On Guide for a Healthy and Active Birth”. This DVD presents 2.5 hours of labor support tools and comfort measures for birth, and many coaching tips for both birthing mothers and their partners In accordance with different phases of the birth.

   Labor tools are in support of the progress of your birth as well as your ability to cope with labor pains.  Labor tools are relating to the physiology and anatomy of birth, and when you practice them, you have better chances of having a healthy birth which progresses in a timely manner (Off course it takes some collaboration from your baby too). It is hard for me to accept philosophies of childbirth education which deny the presence of pain in labor. Contractions are strong cramps of our uterus, and when a muscle cramps, pain is present. So how are you being with that pain and what are we doing when you are in pain? 

When we are in pain, our habitual instinct is to react with fear and tension.  We refer to these phenomena as the Fear-Tension-Pain syndrome. This is our survival mechanism.  Pain is a signal our brain translates as:  “Something is wrong; there might be a risk to the organism”. Neglecting the pain might lead to a serious threat on our survival.  Therefore, we emotionally react with fear and alert; we activate our Fight –Or – Flight syndrome, a remaining of early phase in our evolution and the number one cause of tension and stress. The Fight or Flight syndrome is a set of physiological symptoms, designed to enable us to fight a source of danger or flight when fighting is not optional.  Both these reactions will take: lots of adrenalin, shallow breathing, tightening of the muscles, fast heart rate, and an alert somatic system.

   Now going back to the birth experience, when we react to the pain of contraction with our habitual instincts described above, we are in the way of a good healthy birth.  The uterus works on two kinds of “fuels” –oxytocin and oxygen, both are in charge of effective contractions. In the presence of high levels of adrenalin, the release of oxytocin is inhibited, and our contractions are not becoming stronger and closer together, meaning- Failure to Progress.

We can summarize it this way:  FTP leads to FTP.  Meaning- The Fear –Tension- Pain reaction in birth leads to Failure To Progress.  Labor tools are related to the physiology and anatomy of birth since they allow the mother to de-activate the fight-or-flight syndrome, and by practicing them the mother is suppressing the release of adrenalin, increases the release of oxytocin and the flow of oxygen to her uterus, and reacting to her contractions with acceptance.  Here are some of the labor tools we practice: breathing techniques, massaging, positioning, several visualization techniques, positive affirmations, relaxation, and hydrotherapy.

About four years ago I studied to become a life coach. The coaching practice brought up a new understanding in the way I think about labor tools these days, and led to the development of the Labor Practice.  In coaching we are supporting potent clients in making a change in their lives.  The change can be in the way they act or in the way they are being with something.  A very central term in coaching is the change of the habit. As a life coach I encourage my clients to explore and distinguish habitual ways of doing and being, which do not serve them any more.  These old habits are in the way of getting what we say we want and doing what we say we are committed to.

With this understanding, I was able to see that acquiring the labor tools as part of the childbirth education class is not enough. That if our reaction to pain is indeed a habitual instinct, then it takes a lot more practice for the mother in order to break the habit and rely on a different set of tools. With that thought in mind I developed the Practicing for an Active birth  DVD. This is the most comprehensive Hands-On Visual Guide you can find !  Now couples can watch this DVD at the comfort of their home,  and practice labor tools as many times as they want, until the mother really fells she owns this set of tools.

   The DVD presents a wealth of labor tools – Positions for birth, Breathing techniques, different techniques of visualization – like spiraling of the body and expansion of the belly, Massaging techniques, hydrotherapy and more.  You will learn these tools in accordance with the different phases of the birth. In each phase of the birth, a different progress needs to take place, and I introduce the right tools to invite this progress. Whether it is a release of oxytocin in Early Phase or the engagement of the baby in Active Phase, you will understand the logic behind the tools and how they can best support you in achieving a healthy and empoweirng birth.

Here is a clip you can watch

Birth Coach Method – A Paradigm Shift in Birth Support

What happened the first time I introduced my  coaching method

Last week I had my very first public speaking introducing the Birth Coach Method to a local audience of birth professionals at the South Bay Area California. It was a moment of truth, and I have to confess – I was crazy stressed. It is one thing working diligently on my laptop in the comfort of my home, being fully convinced that integrating coaching strategies into birth support practice is the right direction and another thing to stand and talk in front of birth professionals. An hour before the talk there was no sign to my strong convictions.

My local community is the warmest, most engaged and fun audience I could have asked for. In just a few moments,  I was able to connect to my motivation and strong found conviction, and confidently introduce Birth Coach Method philosophy using the PowerPoint presentation I made.

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Practicing for an Active Birth; Learn a New Set of Responses to Labor and birth.

I have been teaching a childbirth education workshop called “Practicing for an Active Birth ” for ten years in Palo Alto. My students were raving about this class, and the local midwives were continuously recommending it to their birth clients. On November 2012 I launched the DVD “Practicing for an Active Birth; The Most Comprehensive Hands-On Guide for a Healthy and Active Birth”. This DVD presents 2.5 hours of labor support tools and comfort measures for birth, and many coaching tips for both birthing mothers and their partners In accordance with different phases of birth.

After becoming a Life Coach I could reflect on my work in the field of birth from the coaching perspective, and  I realized I want to find a way to encourage my birth clients to practice their labor support tools more than just a couple of times in childbirth education class. I wanted clients to understand that their habitual reaction to pain is in their way to a good healthy birth. Our habit is to respond to pain with rejection and contraction, tightening the muscles. Labor support tools were designed to help birthing moms cope with labor sensations and pain and to invite progress at their birth. But they need to own them, to make a new habit out of them so that in labor they will respond with them to labor contractions and strains. This apparent need for changing the habitual response to pain motivated me to publish this DVD  which allows couples to practice labor support tools at the comfort of their home until they own them. Since its launch, the DVD has been sold on Amazon and getting great reviews.

As a student of the  Birth Coach Training program, you will watch clips from this DVD in accordance with the phases of the birth. This will enable you to practice all the breathing techniques, positions, massage techniques, visualizations and other coaching tools that you want to implement when your client goes through this phase.  The same is true if you are registered to the “Hands-On Series” membership level.

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