Tag: childbirth crisis moments

The Birth Plan from a Coaching Perspective

Is birth plan the goal or the strategy? 

When birth workers, such as doulas and childbirth educators, first envisioned the birth plan in the eighties, the main idea was to help expectant parents prepare for the physical and emotional aspects of the birth process, explore how they want various situations handled during their actual birth, and provide a tool for parents to communicate with each other, their care provider, and the hospital staff prior to the birth (Simkin, 2007; Simkin & Reinke, 1980). As sometimes happens, the mean comes to be associated with the goal, and as such, expectant couples and some birth workers, associate writing the birth plan with achieving it. This association may evoke some unexpected outcomes: 

Continue reading

Five Best Coaching Strategies for Childbirth’s Moments of Crisis

The process of childbirth presents birthing women with some recognized moments of emotional crisis, as well as some unexpected ones, related to the unfolding of the birth. My experience has been that the known and expected emotional crises occur during transitions or changes occurring throughout the process. It is common knowledge that the transition from one phase of birth to another triggers an emotional reaction. For example, the transition from the early phase of labor to active labor is symptomized by the emotional change in which excitement and self-confidence give way to fear, despair, or self-doubt. Birthing mothers express these new emotions in a variety of ways: If they are talkative, they might express them by sharing their thoughts, such as: “Do you think it’s time to head the hospital”? Or “Do you think all these contractions are doing anything”?, “Do you think I’m progressing?” and “How much more painful will this be”? 

Continue reading

Building the Best Support Group for Childbirth- Webinar


How do you Lead your birth clients to build the most effective support group?

To listen to this webinar please buy it here, and we will send you the password.

The most effective coaching questions and strategies to clarify your clients’ needs, expectations, challenges, or concerns arond their birth support group

Don’t you wish to see your clients building the best support group for childbirth? In this webinar, we are revisiting some of the most accepted notions and expectations in regards to birth support in order to suggest a client-centered coaching conversation about one’s support group for childbirth. Common expectations, like partners present at the birth, or the fact that the nurse can’t be a part of the support group as a representative of the medical system, are being revisited from a coaching perspective.

Continue reading

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.

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

0