As a childbirth educator, birth doula, birth doula trainer and owner of DoulaMatch.net, I hear a lot of parents’ birth stories where their doula’s support made a world of difference. Fortunately, and not as frequently, I also hear stories where the doula missed important opportunities for emotional support that left families wondering what exactly they paid for.
Here are two stories that illustrate the pitfalls of under-supporting the earliest parts of labor and offer suggestions for how to respond well to our clients’ emotional needs even before labor begins.
Story #1: “The doula never really showed up for us.” Client signs contract that states the doula arrives to provide support in ‘active labor’. Once labor starts, clients call doula to let her know contractions are 5-8 minutes apart. The doula tells their clients that labor is likely still in the latent phase and that they should call them when contractions are closer together and more intense. After laboring most of the day home alone, the clients decide to leave for the hospital, calling the doula on their way. The doula shows up at the hospital within an hour. The laboring parent is close to pushing. The parents feel the doula provided little support other than to pop by the birth, take a few pictures, admire the baby and leave soon after breastfeeding was established. The doula felt they followed the letter of their contract and that the parents should have called them earlier if they wanted their physical presence.
Story #2: “We didn’t end up needing the doula”. Client’s water breaks before labor starts. Client calls doula to let them know they are heading to the hospital as per their physician’s instructions. Doula tells her clients to call her when they need her. At the hospital, the clients make medical decisions with their care providers to induce labor. After each decision point during the induction, the clients let their doula know via text message. The doula always returns the texts with “when you need me, let me know”. After 12 hours, the texts stop coming. The doula texts 24 hours after her client went to the hospital to find out how they are doing. The doula discovers the client got an epidural and had the baby several hours earlier. The doula is stunned that their clients never called her to come provide support.
What happened in these stories? The doulas in each story failed to recognize their clients’ emotional needs and missed key opportunities to provide support during the earliest parts of labor. How your clients remember their early labor, and how you respond to their communication, sets the tone and their perceptions of your labor support.
Let’s break down the stories above into best practices for supporting our clients during the earliest parts labor:
Take out any reference to active labor from your contract and service agreements. From the 2014 American College of Obstetricians and Gynecologists reVITALize obstetric data definitions database , latent labor is defined as uterine contractions resulting in cervical change from the onset of labor to the onset of the active phase, which begins at 5 cm for multiparous parents and 6 cm for nulliparous parents. The active phase of labor simply marks the acceleration of cervical dilation. As doulas, it’s a mistake to tell our clients our support begins when labor is ‘active’. While that may sound reasonable to parents during an interview and a client may agree to that when they sign your contract, the reality is that most parents need emotional support well before the active phase. Ethical doulas recognize and respond to their clients’ need for emotional support regardless of what phase of labor the client is in.
Respond eagerly and enthusiastically to your clients’ communication. In both of the stories, parents reported their doulas didn’t seem to take their labors seriously. One doula told the client they had several appointments that day they'd rather not miss if labor wasn’t ‘serious yet’. The other doula only communicated with their clients via text and didn’t get to hear the worry and concern in the clients’ voices as they headed into the hospital nervous about what to expect. When our clients contact us, they are passing along information they think we should know. From the doula’s perspective, that information is only half the story. We need to understand our clients’ emotions and feelings. The best way to do that is through a phone call. When your client texts or emails letting you know something is up, always strive to hear your client’s voice. Pick up the phone and call. Acknowledge what your clients told you in the text or email and ask clarifying questions. Find out what your clients are feeling and how they are faring. Ask your clients what their plans are and make suggestions for how you can help. Always end your communications with a next step and time for when you’ll be in contact next.
Intuit your client’s need for emotional support, even when they don’t ask. Sometimes, our clients don’t know when to ask for our help. Perhaps they are worried about ‘bugging’ us too early in the process. Perhaps they are unsure about what a doula does to provide reassurance and physical comfort during early labor. When your client calls you in early labor and seems very anxious and unsure of what to expect, you might consider showing up in person. Ask your client: “May I come over and sit with you to watch a few of these contractions?” When you arrive, you’ll understand how your clients are managing their early labor contractions. Based on what you see, you can provide reassurance, suggestions for finding comfortable positions and strategize ways for your clients to rest, eat and distract themselves with light activities. You may not end up staying with your clients more than an hour or so, but your physical presence may be just what your client needs to bolster their confidence in themselves, their body and their ability to cope. Before you leave make sure your clients know you are ready and willing to return as soon as they need a second pair of hands.
You go when your client goes. Whenever your clients leaves their home for the birth center or hospital, for whatever reason, be sure you offer to accompany them. Think about the client whose water breaks before labor starts. Inevitably, your client will be directed by their medical care provider to go to the hospital to assess the event and baby’s heart tones. When your clients are at the hospital, recognize that part of providing superior emotional support means supporting your clients’ self-advocacy by helping them know what questions to ask when important medical decisions come up. While our clients may not understand the complexity and exhaustion of triage, we know anytime clients arrive at their birth place, there will be a myriad of decisions to make and accompanying emotions to support. Gently offer to your clients your physical presence. Say: “I know there will be many decisions to make depending on your and baby’s health status. I’d like to be there to support you. Why don’t I meet you there?” Sometimes, the greatest support we’ll ever provide is during these early decisions that will ultimately decide the outcome and route of your clients’ births. Don’t miss this opportunity to help your clients ask questions, acknowledge, and process your clients’ feelings and help them make confident, comfortable choices with their medical care providers. Go when your client goes.
- Inductions are special. Inductions can be lengthy and tap our clients’ emotional and physical reserves well before the intense contractions begin. Our sensitive emotional support during all parts of an induced labor can be critical in helping our clients create positive memories of the experience. Think about when your physical presence may be particularly important during the earliest parts of an induced labor:
- During check in at the hospital, you may want to arrive with your clients, helping them settle in, assisting with asking questions about expected timelines and outcomes of proposed induction methods, and ensuring your clients have plans for staying comfortable and confident at the start of the process.
- During cervical ripening, recognize that the unexpected can happen. Some cervical ripening methods can bring on intense contractions quickly. Sometimes babies don’t always tolerate contractions well. Consider being physically present to provide support at the beginning of the cervical ripening process to make sure your clients are coping well. You may only stay for the first 30-90 minutes of the cervical ripening process, but before you leave, make sure your clients know you are ready and willing to return quickly.
- Once the Pitocin starts, consider being physically present for the same reasons above. If your clients are managing well, and if contractions are not present (yet) or still very mild, it may not be necessary to stay, but again, reassure your clients that you can return quickly when anything changes.
Our goal is to promote our clients’ positive memories of their babies’ arrivals. While we cannot predict or control the outcome or route of our clients’ births, we can control how and when we respond to our clients’ emotional needs. Recognizing and responding to our clients’ emotional well-being, especially in the earliest parts of labor, cements our clients’ faith in our steadfast support and contributes to the most positive birth memories.
Kim James, BDT(DONA), ICCE, LCCE, CLE
This article also appeared in the September 10, 2016 DONA International Blog "Best of the International Doula"