Life as a birth keeper

Doulas

'Labour support is centuries old, but its advantages have now been validated in six controlled studies and its positive benefits should not be overlooked.John Kennell, Marshall Klaus, Et Al Journal of the American Medical Association 1991
A doula is a woman caregiver. I love the term coined by Dana Raphael, a medical anthropologist, in her 1973 book, 'The Tender Gift - Breastfeeding', and used by Doctors Klaus and Kennel, in their book. 'Mothering the Mother', The kind of support you would want from your own mother; protective, non-judgemental, calm, experienced, warm and knowledgeable. These pioneers can be seen on this video produced by DONA International, the doula training organisation they founded. DONA video
 'Doula' has come to mean a woman who gives emotional and practical support to a labouring woman, and who remains with her through birth, and if required, enables her to have the most stress-free environment in which to bond with her baby for up to six weeks after birth. Here is a short preview of an English film about doulas, featuring two local doulas who happen to be my wonderful mentors! 
A doula is not a nurse, or a midwife, although, like me, many have been trained as such.  The doula's training means that she will be familiar with the process of labour and birth, and with the complications and medical interventions that can accompany it.  She is not there to make any medical diagnosis or decisions.
The doula protects and maintains a safe emotional and physical space for the mother and her partner.  Her reassuring presence enables mum to let go and surrender herself to the birthing process, safe in the knowledge that she and her partner are protected by a nurturing female companion.  By supporting the birthing woman in surrendering herself to her natural hormonal processes in this way, the presence of a doula can make a profound difference to the birth.
The care a doula gives is totally individual; mum and partner if she has one, will meet up with the doula in the weeks before birth to get to know one another.  This is a safe space for mum-to-be to share her feelings about the birth, and maybe about previous births - what she wants to do, doesn't want to do, and what she may be fearing.  When labour starts the doula can be called as soon as the mum-to-be wants her, and the doula will stay with her for as long as needed.
In the postnatal period, the doula's most useful role is to free the new mother from her daily household tasks so that she may spend precious bonding time with her new baby.  This may involve doing everyday jobs such as housework, shopping, cooking, dog-walking, maybe looking after the older children.   The doula may mind the baby so that mum can get some much-needed sleep or enjoy a relaxing bath.  The doula's training and experience makes her a good listener and she is available if the new mum needs to talk about how the birth was for her, or needs support  with breastfeeding.
"All over the world there exists in every society a small group of women who feel themselves strongly attracted to giving care to other women during pregnancy and childbirth. Failure to make use of this group of highly motivated people is regrettable and a sin against the principle of subsidiary." ~ Dr. Kloosterman, Chief of OB/GYN, Univ. of Amsterdam, Holland
Doulaing is not new; women have had female companionship during labour throughout recorded history. The benefits for the mother and baby of having a doula at the birth cannot be over-estimated.
'I've run a number of marathons. I've done a lot of hiking with a heavy backpack, and I've worked for forty hours straight on-call; but going through labour with my wife was more strenuous and exhausting than any of these experiences.  We could never have done it without the doula.  She was crucial for us.' ~A father.
 Below is some of the latest research about doulas
Cochrane Database Syst Rev. 2011 Feb 16;2:CD003766.Continuous support for women during childbirth.Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario, Canada, M5T 1P8.

Abstract
BACKGROUND: Historically, women have been attended and supported by other women during labour. However in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES: Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2010).

SELECTION CRITERIA: All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS: We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the risk ratio for categorical data and mean difference for continuous data.

MAIN RESULTS: Twenty-one trials involving 15061 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise notedWomen allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% CI 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.97) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition their labours were shorter (mean difference -0.58 hours, 95% CI -0.86 to -0.30), they were less likely to have a caesarean (RR 0.79, 95% CI 0.67 to 0.92) or [COLOR="#ff8c00"]instrumental vaginal birth[/color] (fixed-effect, RR 0.90, 95% CI 0.84 to 0.96), [COLOR="#ff8c00"]regional analgesia[/color] (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low 5-minute Apgar score (fixed-effect, RR 0.70, 95% CI 0.50 to 0.96). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or on breastfeedingSubgroup analyses suggested that continuous support was most effective when provided by a woman who was neither part of the hospital staffnor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.l women should have support throughout labour and birth.
  The power and intensity of your contractions cannot be stronger than you, because it is you.~ Unknown

The physiology of birth

Excerpts from Michel Odent's book "The Caesarean" - Free Association Books, 2004
Let's visualize a labouring woman from the perspective of a modern physiologist.
This leads us to focus on the most active part of her body, that is the glands secreting all the hormones involved in childbirth. These hormonal agents originate in old, primitive brain structures called the hypothalamus and the pituitary gland. In other words, if we visualise a labouring woman as a modern physiologist would, we visualise the deep, primitive part of her brain that is working hard and releasing a flow of hormones.

Today we are also in a position to understand that when there are inhibitions - during the birth process or during any sort of sexual experience - such inhibitions originate in the "new brain", the part of the brain which is highly developed among humans and which can be seen as the brain of the intellect, or the thinking brain. It is more appropriate to call it the new cortex or, rather, the neocortex.

The key for rediscovering the universal needs of women in labour is to interpret a phenomenon which is well known to certain mothers and midwives who have experience of undisturbed birth. It is the fact that when a woman is giving birth by herself, without any medication, there is a time when she has an obvious tendency to cut herself off from our world, as if "going to another planet". She dares to do what she would never dare to do in her daily social life, for example scream or swear. She can find herself in the most unexpected postures, making the most unexpected noises. This means that she is reducing the control by the neocortex. This reduction of neocortical activity is the most important aspect of birth physiology from a practical point of view. It leads us to understand that a labouring woman needs first to be protected from any sort of stimulation of her neocortex. This can be translated in terms of "Dos and don'ts":

DON'T STIMULATE THE NEOCORTEX OF A LABOURING WOMAN!

From a practical point of view it is useful to explain what this means and to review the well-known factors that can stimulate the human neocortex:

- language, particularly rational language is one such factor. When we communicate with language we process what we perceive with our neocortex. This implies, for example, that one of the main qualities of a birth attendant is her capacity to keep a low profile and to remain silent, to avoid in particular asking precise questions. Imagine a woman in hard labour, and already "on another planet". She dares to scream out; she dares to do things she would never do otherwise; she has forgotten about what she has been taught or read in books; she has lost her sense of time and then she finds herself in the unexpected position of having to respond to someone who wants to know at what time she had her last pee! Although it is apparently simple, it will probably take a long time to rediscover that a birth attendant must remain as silent as possible.

- Bright light is another factor that stimulates the human neocortex. Electroencephalographers know that the trace exploring brain activity can be influenced by visual stimulation. We usually close the curtains and switch off the lights when we want to reduce the activity of our intellect in order to go to sleep. This implies that, from a physiological perspective, a dim light should in general facilitate the birth process. It will also take a long time to convince many health professionals that this is a serious issue. It is noticeable that as soon as a labouring woman is on 'another planet' she is spontaneously driven towards postures that tend to protect her against all sorts of visual stimulation. For example she may be on all fours, as if praying. Apart from reducing the back pain, this common posture has many positive effects, such as eliminating the main reason for fetal distress (no compression of the big vessels that run along the spine) and facilitating the rotation of the baby's body.

- A feeling of being observed is another type of neocortical stimulation. The physiological response to the presence of an observer has been scientifically studied. In fact, it is common knowledge that we all feel different when we know we are being observed. In other words, privacy is a factor that facilitates the reduction of neocortical control. It is ironic that all non-human mammals, whose neocortex is not as developed as ours, have a strategy for giving birth in privacy - those who are normally active during night, like rats, tend to give birth during the day, and conversely others like horses who are active during the day tend to give birth at night. Wild goats give birth in the most inaccessible mountain areas. Our close relatives the chimpanzees also move away from the group. The importance of privacy implies, for example, that there is a difference between the attitude of a midwife staying in front of a woman in labour and watching her, and another one just sitting in a corner. It implies also that we should be reluctant to introduce any device that can be perceived as a way to observe, may it be a video camera or an electronic fetal monitor.

- Any situation likely to trigger a release of hormones of the adrenaline family also tends to stimulate the neocortex and to inhibit the birth process as a result. When there is a possible danger, mammals need to be alert and attentive. This implies that a labouring woman first needs to feel secure. The need to feel secure explains why all over the world and down throughout the ages many women had a tendency to give birth close to their mother, or close to a substitute for their mother - an experienced mother or grandmother - in the framework of the extended family or in the framework of the community… a midwife. A midwife is originally a mother figure. The mother is the prototype of the person with whom one feels secure, without feeling observed and judged.


Michel Odent is the French surgeon who introduced water births. He has written many books and doulas are encouraged to read his work


"Will humanity survive obstetrics?" ~ Michel Odent 

                                                                              
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