Can my mother/sister/husband/friend/midwife be my doula?

A laboring woman should be accompanied by whatever people as she chooses. However, the support of professional doula is different from – and complimentary to! – the support offered by loved ones, and that offered by medical professionals.

You wouldn’t expect your partner to stand in for the doctor, or the doctor to stand in for your partner, would you? Of course not! The primary role of the medical team – doctor/nurse/midwife – is to monitor and support the physical health of mother and baby. Doctors, nurses, and midwives typically endeavor to support the laboring woman emotionally as well, but when the birth room gets busy, that’s not their primary task.

So what about loved ones? Well, at my first birth I was assisted by two midwives, my husband, and my mother. My mother is an experienced nurse and nursing instructor. Although not an expert in labor and delivery, you’d likely imagine she’d be able to provide “emotional support, physical comfort measures and an objective viewpoint, as well as helping the woman get the information she needs to make informed decisions,” right? Well, she certainly provided emotional and physical support and gave my partner the breaks he needed, but so far as objective viewpoint goes: NOPE! This was her baby, in pain and bringing forth her grandbaby. In this moment, she was just – and wonderfully – Jackie’s Mommy.

For my second birth, I hired a doula. (I hired Rachel.) You can see her here, working together with my husband to support me through pushing. My midwives are present but out of the shot – because they are busy with the medical work of assisting delivery.Rachel assisting at the birth of Jackie's second child

This does not mean you should not invite your mother or other loved one as well as a professional doula! We strongly believe that women in labor should be attended by whomever they choose (though you may need to check in with your provider’s/birth location’s policies regarding number of attendants). Because just as your mother/sister/husband/friend/midwife isn’t a professional doula (and perhaps even if s/he is), a professional doula knows very well that her role is not the same as you mother/sister/husband/friend/midwife’s. Only the medical team is the medical team, and only your loved ones are your loved ones.

Indeed, although your doula’s primary duty is to you, the laboring mother, most medical professionals and loved ones wind up finding that the presence of a professional doula enhanced their own ability to support the laboring mother. The doula eases the pressure on the partner, and on the medical staff, to fill all the roles all the time. She helps hold the birthing room as a sacred space, in which every attendant is able to bring her or his particular skills and gifts.

Together, we support the mother and her birth memory.

Advertisements

What Should I Do?

From the moment you find yourself standing in a pharmacy staring at the eight bazillion home pregnancy test choices (plus or minus? one line or two? digital?), parenthood is an unending parade of decisions that need making.

Where's the plus sign??

Doctor or midwife? Hospital or home? Cloth or disposable? Breast or bottle? Amniocentesis? Circumcision? Vaccines? Soft cheeses? Stay home or return to work? Work from home? Prenatal yoga? Postnatal yoga? Moxibustion? Caffeine? Weekly vaginal checks? Herbal supplements? Placenta encapsulation? What if you go past your due date? What if the ultrasound indicates a problem? What if your kid drops out of high school, or is gay, or likes football? How will you discipline? Which car seat should you buy? What color should you paint the nursery? Are you even allowed to paint the nursery?

It is the great blessing of the time in which we live that answers are only a few keystrokes away. I know only one person, a music librarian specializing in the obscure, who has in the last decade managed to query Google and get zero results. When it comes to pregnancy, birth, and parenting, every question has been asked, and every question has been answered. There are dozens of reputable websites staffed by credentialed medical professionals providing answers to all the common, and most of the uncommon, maternity questions. There are forums, blogs, Facebook, and the lady behind you in line at the grocery store, too. And, as you will know by the time your pregnancy shows, they all have opinions.

Obviously some of these sources are more reliable than others. Late in my first pregnancy, the teenager bagging my groceries scolded me for buying a 40-pound sack of cat litter. My CNM, on the other hand, had told me to continue my normal activities, just taking a little extra care of my balance and posture. Trusting that my provider knew more about the matter than the bagger, I went ahead and lifted the sack of cat litter. (I also would have taken her advice that people who have lived with cats all their lives, and do not currently have kittens, are at low risk of a toxoplasmosis infection and can safely change cat litter—except cat litter is already one of my spouse’s chores.)

But what happens when the opposing recommendations come from less clear sources than midwife vs. grocery clerk? What if it’s your mother in law versus your best friend from high school? One pregnancy book versus another? Google answers versus a moms’ group on Facebook? What’s worse: a 1:100 chance of mildly bad outcome, or a 1:10,000 chance of very bad outcome? What happens when your sense of what’s best for society doesn’t align with what’s best for your family?

You can try to seek information, you can make lists of pros and cons, tabulate prices and time commitments and what the neighbors will think. But often there is no one right way. In fact, there is almost never a bright and shining sign from the heavens: “Go this way, Mother, and your child will be well, you will be well, and no one will wind up in therapy.” The secret of parenthood – perhaps of life – is this: you do the best you can. You learn, you listen, you reflect, and the you decide. You do the best you can with what you’ve got. Maybe later you learn something new, something that would have made you choose differently. That’s okay. You did the best you could. Maybe your kid grows up to deal hard drugs to children. That’s… Well, that’s not okay. But you couldn’t have known that would happen when you chose the pregnancy test with the + sign.

So cut yourself some slack. Allow that sometimes you’ll be wrong. Sometimes there will be no right. Sometimes you’ll do everything right and things will somehow still go wrong. Sometimes you’ll wish you’d chosen a celibate life as a crazy cat lady and never seen that dratted + sign at all. Except in the next breath – or more likely in the same one – you’ll never wish that at all.

What If My Baby Is Too Big?

One worry common among pregnant mamas is that they will grow a baby “too big to birth (naturally).” We’ve all heard the horror stories – and maybe seen the photos on the internet – of 10, 11, or 15-pound whoppers of newborns. And most of us receive at least one third-trimester ultrasound, a standard part of which is the estimation of fetal size. So, just what are the risks of a large baby, and how should we proceed?

First, we need to know what constitues a “big” baby. There are two kinds of “big”: macrosomia and large for gestational age. Macrosomia, or “large body,” can be alternately defined as a birth weight greater than 8lb 13 oz (4000g) or one greater than 9lb 15oz (4500g). Slightly over 7% of American babies are born greater than 4000g, and slightly over 1% weigh more than 4500g at birth. Large for gestational age (LGA), on the other hand, is the medical term for any baby born over the 90th percentile for babies born on the same day of pregnancy (how many weeks and days pregnant mama is when baby is born). By definition, 10% of all babies are LGA.

Your baby’s birth weight is influenced by many factors, including maternal and paternal height, whether mom was obese prior to pregancy, mom’s weight gain during pregnancy, baby’s sex, and chemical exposures including smoking. By far the biggest risk factor for unusually (and unhealthily) large babies, though, is gestational diabetes. Like other pregnancy complications, gestational diabetes carries its own list of risks for both mom and baby, and is to be taken seriously.

However, even in the uncomplicated pregnancy there are certain complications associated purely with fetal size. Most of these are a result of the increased mechanical demands of a larger baby passing through the birth canal. Labor is more likely to stall, vacuum or forceps delivery is more often necessary, and perineal tearing and pelvic/tailbone trauma are more common. The increased risk most cited by physicans is also a mechanical complication: shoulder dystocia, which is quite simply the baby’s shoulders getting stuck behind the mother’s tailbone after the head is born. Although shoulder dystocia is more common among large babies, it is not altogether uncommon in babies of any size, and it can nearly always be managed with relative ease when it does occur. (And, lest this all seem rather bleak, there is some good news for parents of larger than average babies: big newborns – up to about 10lbs – grow up to be more successful grade school students.)

Thus it would seem that prenatal diagnosis of fetal size would be useful information for a birth team, right? After all, surely that is the reason two-thirds of US women receive late-pregnancy u/s to estimate size. Well, yes and no, for it turns out these estimates are notoriously inaccurate. Of the many formulas used to estimate birth weight, the very best formula is within +/-10% of baby’s weight only 70% of the time. All formulas work best on mid-sized babies. Using a little back-of-the-envelope math, this means that, if you’re told your baby is “large” or “very large”, there is at least a one-in-three chance that your baby’s real weight is a whole pound different than the estimate you’ve been given. In fact, with most methods there is little better than a 50/50 chance that your “suspected large” baby is in fact macrosomic – about the same accuracy as a physican’s guess after feeling the mother’s belly, and only moderately more accurate than just guessing every baby at 3455g (7lbs 10oz, or perfectly average).

As unreliable as fetal size estimates are, however, they can have a marked impact on pregnancy and labor management. As many as two out of three physicans will propose induction, and as many as one in three will propose scheduled cesarian, on the basis of such an ultrasound finding. Additionally, doctors are more likely to diagnose the labors of suspected large babies as failing to progress, thereby setting off a string of interventions to speed/assist the birth, even when those labors are in fact progressing at the same speed as labors without suspected large babies. Comparing labors in which a baby that was both suspected to be and actually large with labors in which an actually large baby was not previously suspected, the suspicion of macrosomia markedly increases medical intervention without significantly changing outcomes. The American College of Obstetricians and Gynecologists specifically names macrosomia as an insufficient reason to induce birth (or schedule a cesarian) prior to 39 weeks gestation.

So, while it is certainly true that big babies can be hard to birth, it is not necessarily the case that estimated fetal size alone should alter an expecting mother’s plans. After all, babies of any size can be difficult to birth. Quite often the culprit in a difficult birth isn’t baby’s size so much as baby’s positoning. The strategies for vaginally birthing a large baby are really the same as those for any other baby: using good posture through late pregnancy, and utilizing motion and gravity during labor. Certainly, it is true that a large baby has less room to maneuver during birth, which makes such positioning tactics even more important.

Whether your baby is large or small, your doula can help you try out labor positions and techniques including walking, dancing, kneeling, leaning, lunges, and squatting. Even with an epidural, periodic position changes help the baby ease its way down the birth canal and into the world.

References

Dekker, Rebecca. “What Is the Evidence for Induction or C-Section for a Big Baby?” Evidence Based Birth. http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/

Nahum, Gerard G, MD, FACOG. “Estimation of Fetal Weight.” Medscape. http://emedicine.medscape.com/article/262865-overview#aw2aab6b2

“The Dangers of Estimating Fetal Weight Near Term.” The Well-Rounded Mama. http://wellroundedmama.blogspot.com/2012/09/the-dangers-of-estimating-fetal-weight.html

“Optimal Fetal Positioning.” Spinning Babies. http://spinningbabies.com/about-spinning-babies/optimal-fetal-positioning

Leonhardt, David and Amanda Cox. “Heavier Babies Do Better in School.” The New York Times. http://mobile.nytimes.com/2014/10/12/upshot/heavier-babies-do-better-in-school.html?referrer&_r=2

How the YMCA and the Village People can help your Breastfeeding Relationship

Image

I don’t know anyone who has breastfed; how will I get the support I need?

You will have to build your own support network, but don’t worry there is help out there!  There are many online communities like kellymom.com as well as local support groups like La Leche League that can help you connect with other nursing mothers.  I like to use the acronym YMCA to help other moms find some village people to help establish the support they need:

Y-Your family (your husband and mom can be very influential cheerleaders)

M-Medical professionals (find a lactation consultant and a good pediatrician)

C-Community groups for breastfeeding (La Leche League, Breastfeeding USA)

A-Any breastfeeding moms you know (new mom’s groups, church, high school friends, etc)

My breastfeeding story

To illustrate, I’d like to share my breastfeeding journey, and how the Village People and my YMCA saved my breastfeeding relationship. You might have a baby who is an expert nursling, but you might also need all the help you can get!

3rd Trimester

The Road Block: Lack of Knowledge

The Village People: Birth Class

The Support:  My husband and I signed up for a birth class that offered a FULL CLASS of breastfeeding education, and an introduction to the concept of a doula, who was essential to our birth and breastfeeding support.

The birth

The Road Block: A broken tailbone and a baby who wouldn’t latch

The Village People: A doula and my husband

The Support: Our doula went above and beyond, stayed for FOUR HOURS after our birth and called her mentor for instructions on how to teach my husband to hand express colostrum while I was out of commission.

The first few days

The Road Block: A refusal to latch, jaundice, weight loss, painful engorgement

The Village People: my mom, 2 IBCLC’s, a lactation counselor, and our pediatrician

The Support:  The hospital lactation consultants worked tirelessly to help us out, and my mother supported me through tearful phone calls at all hours of the day. At our first Ped appointment, our pediatrician could have just handed us a can of formula, but instead she rushed us into see a lactation counselor, who taught me how to use a breast pump to relieve engorgement and how to feed my son a bottle until we could get a latch.

Six weeks

The Road Block: Pain, and lots of it

The Village People: My husband, our childbirth educator, an IBCLC, and a cranial-sacral therapist

The Support:  Thanks to the pump and bottle, our son was gaining weight, but the latch was still wrong.  I thought about giving up, but my husband encouraged me to speak to our childbirth educator, who referred me to an IBCLC.  She diagnosed an upper lip tie and taught me how to adjust my son’s latch.  It helped a little, and combined with a referral to a cranial-sacral therapist, our son was finally latching pain-free within a month.

2 months

The Road Block: Colic and later, projectile vomit after every feeding

The Village People: A lactation consultant, a pediatrician and a mommy friend

The Support: The lactation consultant was able to diagnose an oversupply issue and the pediatrician suggested my son might have a dairy allergy.  A mommy friend helped me adjust to the new diet, and within days the hours of endless screaming had stopped.

4 months

The Road Block: Teething and biting

The Village People: Nurse and Chat

The support: Within a few minutes at Nurse and Chat, a lactation consultant gave me several tips to help me nurse a teething baby who was using me as a teething ring. It was that easy, but imagine if I had never gone in!

8 Months:

The road block: A lack of sleep from a babe who wanted to nurse all night

The Village People: La Leche League, New Mom’s Group, and our pediatrician

The support: Old friends from my New Mom’s Group suggested I read the No Cry Sleep Solution, and my local La Leche League had it to borrow from their lending library.  Our pediatrician gave us words of encouragement at our son’s nine-month appointment, and it really helped to lift our spirits.

And beyond:

I know that as my son approaches toddlerhood, our nursing relationship will change again.  Because I have my own personal YMCA, I will know whom to call to get my answers so that I can have true success feeding my child.  For all you expectant and nursing mothers out there, I hope that you can also build a network to support you through your breastfeeding years