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Choosing to Cross Certify as a Doula With BirthWorks International

As I read “Doulas of Love” by Cathy Daub, I was reminded about why I am seeking dual certification as a doula with BirthWorks. As an experienced birth doula, I was familiar with many of the topics since I am a certified Childbirth Educator with BirthWorks. But there was an aspect of the guidebook that was refreshing, and it was admittedly the uniquely BirthWorks part. I think the best way for me to articulate what I learned through my reading would be to
explain what I found to be the most important.

Human Values through the Five Senses is a wonderful goal for my work not only as a doula but also in my life. And taking in the five human values through the five senses illustrates the importance of completely incorporating human values into our daily lives. And I feel I do that. I strive to speak honestly, to encourage and not tear down. I eat (mostly) healthy foods, and exercise my body regularly and support my clients in doing the same. During their births I am constantly helping them to see the positives and the benefits to the hardships that come their way. Labor is hard, but that’s part of the process. To be present with women and help them to see past the difficulty into the learning and transformation that labor brings, is an honor and essential for their positive memories of the birth. I am humble in their strength, and I am calm in their anxiety. I was encouraged to know I already use human values in my doula work.

The second thing that really spoke to me was the explanation of the Three H’s of “Head, Heart, Hands.” The hands should only carry out what is approved by the heart and considered in the mind. The subconscious actions do not consult the heart and manifest as reactions rather than responses. Again, I was encouraged to know that I follow what my heart feels is right and am privileged to work with many providers who do the same. I also found it interesting to consider how sometimes women in labor act from their subconscious, reacting with outbursts
in labor, instead of calm responses. This makes sense though, since a laboring woman, while also feeling with her heart, is less in her frontal cortex, the thinking brain, and far more in the limbic portion of her brain where the subconscious lies. So when a laboring woman acts in this way it can be considered a positive, for it is a sign that she is deep in her labor.

Doulas who practice serving from their hearts, exemplify the BirthWorks Human Values and character training. I have heard doulas and the work we do described as heart work. This is a very intimate job. Our role is very personal and we are present with our clients during vulnerable and intimate moments. It’s of utmost importance that we are respectful and serve unconditionally, meeting our clients where they are. In order to do this truly we must speak
with our hearts and serve that same way. It is not our birth but our clients’ birth. And as such, it’s also important that we respect their decisions even if they wouldn’t be our decisions.

That took me time to learn, but I wholeheartedly believe it now. There is book knowledge about stages of labor and comfort measures. But the true value we bring to a birth is our hearts. The rest will come but if we are not connecting with our clients through our hearts, then all of the techniques and knowledge will fall flat. Incorporating and practicing Human Values goes both ways—the way I serve my clients, and also the way my clients walk their journey of pregnancy, birth, and parenting. Being reminded of the importance of processing my decisions
through not only my brain but also my heart can do so much to encourage my words and actions will help and not do harm.

I also love how the BirthWorks human values approach to doula certification doesn’t stop there. These values are also important to use in life. And these are the parts of my doula work that I find most challenging. Not for me. But when I see providers and nurses acting in ways that don’t respect human values it’s very difficult and it upsets me. As doulas we are caught in the middle. We cannot undermine or oppose providers, for that does not instill
confidence and safety in our clients. My role is to protect the emotions of my client and help her to feel calm and secure. My job is made more difficult when a provider is not using human values in their approach. Thankfully, I rarely encounter this. But I realize there are doulas who are constantly struggling with the cognitive dissonance felt when the providers’ actions don’t reflect human values.

The next thing I found notable in Doulas of Love was being reminded of the deep affect our relationships with our mothers can have on our pregnancy, birth, and mothering. I have a very good relationship with my mother, however I have worked with clients who are not as fortunate. I see how difficult it can be to incorporate their mothers in their birth in a healthy way, and some choose to disengage them for the sake of preserving their experience. We discuss the importance of being selective about one’s support team, but I also remind them it’s critical to communicate feelings even if difficult. It’s all very complicated, that’s for sure. And while it can be hard information to process, and even feel a bit too overblown to me, I don’t recall there being any mention of the mother/daughter relationship in my other trainings.

In helping a woman in labor to relax, I highlighted the line “It is important to remember that the most comfortable position may not be the most effective one.” I agree with this mostly. I see it happen often when a client lies down and finds the contractions ease a bit. Rest has its place in labor, but I know women often prefer it because it is less painful. This is the case in early labor. For we know in active labor it can be more difficult and uncomfortable to lie
down. However, I have served clients for whom when they feel pain, if it’s localized to one area, like on their left or right hip, it may signify a problem and not so much the progress of labor. It could indicate that the baby is in a less than optimal position and thus would require some intentional maternal positioning to encourage baby to move off the one hip. But I agree almost entirely that the less comfortable a position the more productive the position.

I appreciated the reminder of the importance of holistic nutrition as well. Nutrition is not just what we put in our mouths; it is also what comes through our eyes, ears, out of our mouths, and into our minds and hearts. That is profound and illustrates just how extremely influential the messages are that we take into our bodies, not just the food we eat. The messages are all nourishment to us or poison, depending on what it is saying. The section on birthing language really spoke to me. I had not previously given much thought to the significance and underlying meaning behind the word support, not until I heard Michel Odent, MD explaining why the word robs laboring women of their power. It changed my verbiage and now I consciously avoid that word. I have replaced support with serve and I do it now without thinking. It’s so important that we always remember that the woman is the one
birthing her baby, not the partner, not the doula, and not the nurse, nor the provider. As soon as we forget that she is the one birthing, we disengage her from the process and walk the dangerous line of doing things for her or to her, rather than having an open dialogue about what it is she desires and feels is the best course of action. Counsel and explanation of options from the provider is of course welcome and helpful, but the decision should be made by the
woman.

If we are to truly believe our clients have the knowledge and ability to birth the way they need to, then we need to avoid considering ourselves an expert. I never want to feel I’m the expert at a client’s birth, although sometimes they paint me out to be just that. The knowledge of comfort measures and labor stages and nuances can easily make us come across as one, as well as the sheer numbers of births attended. But I’m constantly checking myself to
make sure I am respecting the mother as the one who knows best and only offering insight and ideas when relevant or requested for I have never attended her in this particular birth. The only one who is an expert in her birth is her. Knowing and truly believing this, I use my heart to determine whether I should say or do things that are to “help”. I weigh it very carefully before proceeding. And I think BirthWorks’ approach articulates what I feel my doula approach has become.

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BirthWorks Reborn by Stephanie Parry, BWI Childbirth Educator and Birth Doula Student

The birthing of my career as a childbirth educator and doula began over 18 years ago, on a cold fall evening as I pushed out my VBAC baby into the bed he was conceived in, surrounded in peace and love and welcomed earth side by his parents, grandmother, and loving midwives. There is something so otherworldly and generational when a baby’s first introduction to human life involves dim lights, hushed voices, warm hands, and landing safely on mother’s soft breast. How I wish all babies were introduced to this world in such a manner. Not all of my six children were born in a gentle way, but because of my knowledge and inner knowing of the BirthWorks philosophy, my children were all consciously
welcomed in awareness and peace.

Life has brought me great surprises through raising children, navigating a divorce, and entering the life of single motherhood. And though I have had to take other jobs to provide an income for my growing family, always my heart has been with birth work… my life’s passion to witness and hold space for the women who birth themselves as they birth their babies. I have found that the choices I made in life to raise my children often coincide with how they were birthed… in love and peace and with a lot of wide open space for them to feel safe to explore who they are.

Recently, as I was attending a therapy session to release some past trauma and difficult feelings that I was holding onto, I was led into visualizations that reminded me so much of the work we do in our BirthWorks childbirth classes that it bought me back in time in my body to a workshop many years ago while attending training with Cathy Daub. Cathy was helping me release and deal with the grief from the separation from my daughter after her traumatic cesarean birth a few years before. The three day separation from her had caused significant trauma and guilt that I had not yet dealt with. It was crucial to release this in order to move forward in my path as a childbirth educator and doula. When Cathy led me through the guided visualizations to help my body create a new memory, I was holding my baby in my arms as soon as she was born. This is the memory my body has of her birth now. And I was changed from the inside out.

As I sat through the therapy this past week releasing feelings of grief and hurt, my body instantly reminded me of my experience during that childbirth training so many years before. And I knew in that moment where my next step was… that I belong with birthing women. One of the most amazing things about BirthWorks has been the inner knowing and trusting of my own intuition that it has instilled in me. How easy it is to forget who we are and what we are all about in the busyness and chaotic pace of life. And how easy is it that in a moment our body can remember and teleport us back to a time that has been imprinted into our cells.

The world is in the middle of a tumultuous and uncertain time. Yet, life continues on and babies will be born. And so it is a deep honor and with gratitude that I step back into the path of serving birthing women and their families and accept my calling alongside the women who have paved the way before me.  I am BirthWorks reborn!

Blessed be.

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Where is the pelvis? The Importance of an Upright Pelvis in Birth

We often ask, “Where is the baby?” in a pregnant woman, but even more important is the question “Where is the pelvis?”  A new vision is urgently needed in birth.  Anatomically, babies are supposed to be born “out the back.”  In the diagram here of a woman on a bike, note that even in an upright position, small movements in posture affect the angles between the spine and the pelvis.  The arrows depict the direction in which the baby will be born. Today, most women are lying on their backs birthing their babies “out the front” which makes birth more difficult.  Anatomically, babies are supposed to be born “out the back.”

Even though we are not always aware of it, our bodies are always in constant motion with the heart beating, lungs breathing, and blood vessels carrying precious nutrients throughout the body and excreting what is not needed.  Gravity plays an important role in these processes.  Even a newborn needs to start learning anti-gravity positions to start the process of being upright and eventually creeping and walking.  The human body wants to be upright and active to function efficiently.  This includes birthing a baby.

We have gravity because of the dynamic equilibrium of the Earth moving around the sun. The speed with which this happens creates a centrifugal force that balances the gravitational force between the Sun and the Earth.  Gravity is so important to our very existence that astronauts in space need to exercise at least two and a half hours each day to give the body a sense of weight-bearing.

It is much easier and more comfortable to defecate in upright positions.  In the same way, it is easier and more comfortable to birth our babies when the pelvis and the organs within it are in upright positions.  Just picture a section of a water hose held upward at either end.  If this was the birth canal, imagine how much more difficult it would be to have to push the baby up against gravity to be born – yet this is exactly what most women do!  They are lying on their backs with knees pulled up and out making birth much more difficult.  How much easier it would be to turn around onto hands and knees or on knees leaning over a birthing ball or pillows on a chair, or lying sideways with the pelvis shifted forward, or even standing, allowing gravity to be their friend!

Standing, holding onto a rope and taking weight off the feet offers a very important aspect of giving birth not much talked about.  This is the effect of stretch receptors feeling the stretch upward on the upper body.  It is helpful in labor to have the forces going up balancing the forces going down.  It is believed that stretch receptors actually play a part in signaling a woman’s body to go into labor. Gravity plays a role when giving birth as well.

The way in which a woman in labor postures herself, is likely to affect the way the entire birth may go.  This is because the baby has more space in which to move when the pelvis is tipped forward in upright positions.  This allows the baby to move into advantageous positions to move and rotate through the pelvis and helps to prevent dysfunctional labors.

The pelvis lying down appears very different than the upright pelvis.  Even slight angles forward make a huge difference in terms of how the baby comes out as can be seen in the diagram.   Lying down flat on the back, a woman is lying on her sacrum.  The sacrum needs to move forward and backward which actually changes the available space in the superior and middle inlets.  In an upright position, the pelvis is already, normally in an oblique position, tipped forward.  Add to that the help of gravity assisting the baby in coming down, and a laboring woman moving her body, changing positions, all of which can make labor easier. At the same time, the uterine muscle, itself, is working hard to contract down to help the baby move into the pelvis.  If a woman allows gravity to assist this process  by keeping herself upright or at least with her pelvis forward, she is likely to have a shorter and easier labor.  Of course, add to that the presence of a doula or birth companion so she feels safe, and the experience can be much more positive.

If you have seen women in labor lying down, you may notice something interesting.  This has to do with the Rhombus of Michaelis.  These are a bundle of nerves by the low sacrum that have a role to play in labor.  The baby in an OA or Occiput Anterior position, will flex or bend his head to put pressure on these nerves just before the moment of birth.  The mother will reflexively respond by lifting up her left hip and knee with a slight puffing out in her low back. This opens up the birth canal for birth so the baby can be born “out the back.”  With an epidural, you can see women trying to lift up this part of the back with none or limited ability to do so.

So which way do you want to birth your baby? With gravity or without gravity?  It is as simple as that!  Become familiar with upright, forward leaning positions for labor.  Try them out while pregnant so they become familiar to you.  Then know that these are optimal positions for your labor.  But if you need a rest, sidelying with an anterior or forward pelvis is also a good option.

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WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections1

Just 40 years ago when I first gave birth, a cesarean was still considered an operation done only for specific life-threatening conditions as well as when having had a prior cesarean.   Today, it has become an accepted, if not almost routine, way of giving birth.  What has caused this significant and disturbing trend?  Concerns about the sustained and unprecedented world-wide rise of cesarean section has prompted the World Health Organization to issue this report.  In the “WHO Recommendations Non-clinical Interventions to Reduce Unnecessary Caesarean Sections, they stated, “This is a major public health concern. There is an urgent need for evidence-based guidance to address the trend.” Their report was based on evidence of the effectiveness of interventions from an updated Cochrane review of 29 studies.

The importance of this WHO report is that it represents the first global guidelines of a clinical encounter between a health-care provider and pregnant woman in the context of patient care. The purpose of the study is to “provide evidence-based recommendations on non-clinical interventions that are designed to reduce cesarean section rates.” Their report acknowledges that a cesarean is a surgical procedure that when necessary can prevent maternal and newborn mortality when medically indicated.  However, beyond a certain threshold at risk, may result in increased maternal and perinatal morbidity along with both short and long-term health risks that may extend for decades beyond.  This in turn results in substantial increases in health-care costs, morbidity, and mortality for mothers and babies.

In the USA, about one in three births result in a cesarean, having increased dramatically from 5% in 1970 to over 32% in 2016. Today.  it seems to matter what country you are born in and in the USA, which state you live in. In the USA it is better to be born in Utah (22.3%), Idaho (21.9%), New Mexico (24.8%),  Alaska (23%) or Hawaii (25.2%) versus Mississippi topping the list at 38.2% or Louisiana (37.5%), Florida (37.4%), West Virginia (34.9%), NJ (36.2%) or Connecticut (35.4%).

Internationally, Finland has a low cesarean rate of about 16% of births and the UK’s rate is about 24%. Brazil tops the list at more than 50% with even higher rates in private sectors.  Latin America and the Caribbean follow with high cesarean birth rates at 40.5% and North America (32.3%) ranging down to Asia (19.2%) and the lowest in Africa (7.3%).

When cesarean rates vary to this degree, it must be due in part to how birth is managed rather than birth itself. The international health-care community has considered the ideal rate for caesarean section to be between 10% and 15%.  WHO concluded that “at the (global) population level, cesarean rates above 10% were not associated with reductions in rates of maternal and newborn mortality.”

The WHO report acknowledges that although societal changes such as increases in obesity, multiple pregnancies and older pregnant women have contributed to the increased cesarean rate, these are unlikely to explain the variance  of cesarean section rates between various countries or states.  Other non-clinical factors such as women wanting to plan their birth dates, physician factors, malpractice fears, and other economic and social factors are also implicated in the high variability of cesarean rates.

We know today that there are many non-clinical interventions that have proven to be successful in labor and birth but which are underutilized by most women, birth professionals, and facilitators.  These include warm water, optimal pelvic positioning,  the presence of a birth companion or doula, massage, speaking encouraging words, and keeping a positive and private environment.   On the contrary, medical intervention rates are very high with for example a 75% rate of epidural anesthesia and other obstetrical drugs to control pain.

In the WHO report, recommendations to reduce cesarean targeted women, health care professionals, and health organizations, facilities, or systems.

For women

  • Education that addresses fear of pain, advantages and disadvantages of cesarean sections and vaginal birth, risks and benefits of pain relief techniques and obstetrical drugs, and guidelines for indications and contraindications of cesarean sections.
  • Relaxation training and stress reduction programs conducted by nurses
  • Couple-based prevention programs that are inclusive and provide problem solving suggestions, mutual support strategies, and conflict management.
  • Psycho-education for women who fear childbirth itself and that address topics such as normalization of individual reactions, stages of labor, hospital routines, birth process, and pain relief.

For Health-Care Professionals

  • Implement “evidence-based clinical practice guidelines combined with structured, mandatory second opinion for cesarean section” in settings with adequate resources and senior clinicians.
  • Implement “evidence-based clinical practice guidelines, cesarean section audits and timely feedback to health-care professionals.”

Health Organizations, Facilities or Systems

  • Establish a collaborative midwifery-obstetrician model of care where the model of staffing is based on care provided primarily by midwives with 24-hour back-up from an obstetrician who provides in-house labor and delivery coverage.
  • Establish financial strategies such equalizing physician fees for cesarean and vaginal births.

The highest level of certainty evidence was the recommendations for health-care professionals where accountability was required.  Interventions in labor and birth need to be guided by the basic premise that if the harms clearly outweigh the benefits for valued outcomes, they should not be used.

The WHO report stated that women find learning new information about birth to be empowering  but it should not provoke anxiety.  Women want emotional support alongside the communication of facts and figures about birth. But interestingly, there seemed to be no differences in cesarean rates based on computer-based decision aids, booklets, role play vs lecture for women with fear of childbirth, or educational brochures in spite of the fact that women seemed to want such things.

They did not see differences among various ways to present the childbirth information, but none of the discussed formats for learning included an experiential and emotional preparation for birth that is based on basic human values as is available in BirthWorks.

BirthWorks childbirth preparation is designed to build confidence for birth.  We offer a broader systems approach to childbirth that is based on a foundation of human values where optimal pelvic positioning is key.  Women learn how to work with their bodies in labor, knowing that the knowledge about how to give birth is already born within every woman.  Included are also identifying beliefs and releasing fears thus re-framing them to a positive experience,  the role of hormones and the value of the microbiome as well as the importance of mother-baby skin-to-skin contact, mother-daughter relationships, the value of doulas, and grieving and healing.  Classes are interactive and a place of joy and learning which is what the experience of birth can be.  BirthWorks childbirth preparation builds confidence and decreases fear through the integration of mind, body, and spirit.

Reference:

  1. World Health Organization 2018. This report is available under the Creative Commons Attribution –NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO, https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
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Reflections From A Mom With Multiples

Taking care of one baby is a lot of work.  New moms often say they were busy all day but don’t exactly remember what they did!  Just imagine taking care of newborn twins or triplets!  I am a BirthWorks Mentor and one of my students, Sienna Morrow, who is in the BirthWorks Postpartum Doula Program sent a response to the question below that brought me to tears as it made me remember my own experience with my twins.

Question:  When is a baby considered to be premature?  List five main concerns a new mother with multiples might have in the first few months at home and how you would address them.

She wrote:

  • A baby is considered premature if born before 37 weeks.
  • A mother with multiples might be concerned with getting adequate sleep, breastfeeding two babies (tandem), creating a routine that works for both babies, bonding with each baby, and having enough support.
  • I would encourage the mother to tune into the babies and create a routine that works for all of them together by helping her process how things go throughout the days and areas where she is struggling.
  • I would help her connect to groups of moms of multiples in her area and give her time to have conversations with her partner about how they can support one another.
  • I would address any breastfeeding concerns that she has and build up her confidence with praise and words of wisdom.
  • I would also help her explore her own resources and discover things she can do to build a support network in her current situation.”

I, myself, gave birth to my twin boys at 38 weeks and 6 days so they were not premies. I breastfed my boys 21 of 24 hours the first day, and then it was like 16 hours a day until we all learned to tandem feed. I felt stuck in my primal brain for weeks, almost like having no awareness of being human most of the time.  As I reflect back on the experience, I am laughing, remembering some of my chimpanzee robotic-like thoughts that were running through my head during that time:

  • Feed next baby, get other one, feed other….fall down and sleep…are they both safe? …zzz…wake up! Baby must eat…
  • I starving, ravenous, soooo thirsty, give me water
  • Bladder bursting, need to pee
  • Need shower, crusty, smelly, sweaty, sticky
  • Where is Annalissa? (That’s my daughter who just turned four.  This thought would come with adrenaline as I was falling asleep feeding some baby boy – not sure who it was half the time, didn’t care, trusted my husband who rotated them.

These thoughts just repeated over and over, like the film “Groundhog Day”, until around four months.  Then, I woke up, like from a dream, checked we were all alive and when we were, I sighed deeply.

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Creating Sacred Space for Birthing

Guest Post By Bethany Hays, MD

We are the guardians of the most sacred moment in the lives of women and their families, with implications for the long term health of both. That moment is when nine months of hopes, anxiety, planning, purchasing, celebrating, putting up with being uncomfortable, being too big, being not big enough, being in pain becomes separation, relief, responsibility, and falling in love.

Continue reading Creating Sacred Space for Birthing