Tuesday, October 12, 2010

Reply turned post, on a 360-degree view of the doula's role

Birthday Nurse wrote a post recently on, in part, the role of the doula in the birthing room:

One thing I always seem to struggle with when I have patients who have doulas is when they ask their doulas for "permission" before they do anything. The patient was thinking about getting an epidural after 10+hrs of backlabor and no real cervical change. She had been talking about it and going back and forth and I asked her if she wanted me to start her fluid bolus prior to her block. She looked right at her doula and said "what do you think?" When her doctor wanted to start pitocin a few hours later after she was comfortable and still not changing her cervix...again she looked at her doula and said "what do you think?" (after waking her doula up from the nap she had been taking on the pull-out mattress) HELLO!! This is not your doula's labor! This is your labor, your baby, your body, your experience! You don't need your doula's permission!!! Doula's are great support people, they're awesome, don't get me wrong. But (most of them...and especially not the one in the previous scenario) they're not trained medical personnel...they're not your doctor or your nurse...don't ask their "permission"!

My reply turned into a post of its own, here in somewhat edited form:

I have a couple perspectives to share on the "permission" thing. Sometimes as a doula I get clients looking to me for "permission". I understand what they're doing, they hired me in part to be a sounding board and an independent voice, and they want to know what I think. Because it's not my role to give them medical advice, I generally try to turn it around and talk them through the situation and ask what more information THEY need to make a good decision. I wouldn't want a client asking me for actual permission if her doctor told her she needed a c-section. But if she turned to me and asked what I thought, and it meant I could help her talk through the facts that baby was showing no distress and that her progress was slow but was happening, that might be a good thing for her having what she needs to make an informed decision about whether or not she wanted to consent to the section. If you have the independence as a nurse to give her the space, time, and support to potentially question her doctor's recommendation, that's fabulous! But many nurses don't, or won't, and I feel that's where the doula's ability to be an independent sounding board comes in.

And sometimes I also recognize that as someone they shared their birth plan with, and trust, they just need emotional validation for the path they're about to choose. It would be nice if they could get that validation from the medical staff, but unfortunately many people who hire doulas are doing so because they do not completely trust the medical staff - and sadly, with good reason in some cases (this brings us back to the need for an independent sounding board.) They need someone who they know is totally on board with their birth plan to affirm that it's OK to deviate from it. So in those cases I can be the one to say "You seem so exhausted, I agree an epidural sounds like a great idea", or whatever it is they need to hear to feel good about their decision. A doula friend told me recently that she actually asks her clients, "Do you need me to give you permission to _______?" as in, do they just need some help to feel OK about their decision?

I have experienced this from the other side (albeit less often) doing lactation support where the mom looks to her doula when I recommend, for example, a nipple shield. "Do you think I should try it?" And I get this flash of irritation - "Your doula didn't train for this work and take the LC exam and work with hundreds of breastfeeding dyads, why are you asking HER?" - and then I go "aha, this is what the L&D staff must feel like when my doula client turns to me!" So in that moment I remind myself that I have just met this woman - why should she trust me? She trusts the person who she met and has been working with for weeks, and just went through many hours of labor with, and she is trying to make an informed decision that (gasp) may not be what I recommend. She is going to consider her options and make a decision instead of just agreeing with what I suggest, which is a strange feeling for me but a good one to get used to. I may not agree with her decision but she will be the one who lives with the consequences, not me, and I have to make room for the possibility that I am wrong and she is right. That this is so uncomfortable for me to do has been an excellent learning experience and given me a lot more sympathy for all sides!


Kristen said...

I'm so glad that you shared your perspective on this issue--including your sharing how it felt for you as a LC when a woman turned to her doula to ask for "permission."

I completely agree that what this represents is far more than simply a woman seeing her doula as an authority figure who can give her permission to do x, y, or z. It's about trust, validation, reassurance, and a relationship that she and her doula have built over an extended period of time--far more time than many of the hospital staff have (presumably) spent with her.

With that being said, I hope you included all or most of this in a reply to Birthday Nurse!

Karen Bayne said...

Thank you so much for sharing that. When we are in the role of "expert" we expect compliance, agreement. It does not feel good to have someone seem to not trust us - after all, we know how much we've studied, how long we've worked. However, you are right.
Clients/patients are looking for information they can trust, which means they are often looking for a trusted source.
I appreciate the story you told because it shows all of us that we can treat women with respect whether or not they choose what we would choose. Nice going!

Stephanie said...

Great post. As a doula, this is awesome perspective and good food for thought when it comes to meditating on the language I can use to maintain peace across borders (know what I mean?). Thanks.

Expectantly Looking Forward said...

Having been on several sides of this issue, you have done a great job explaining it. As a L&D nurse there are times when you just don't have time to build the trust with your patient before important decisions need to be made. I love it when a patient has a doula.
Stacy Lowery Pagan

Nicole said...

I have to point out, that when a woman says "what do you think", I don't think she is always asking for PERMISSION. She is more likely asking for other perspectives, more information, or a chance to go back and forth with someone she knows and who knows her. Talking to her "independent sounding board" is a completely different thing than "asking permission".