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Keeping Doulas at Births in Hospitals During Covid-19

Stages of Grief: Our community was thrown off-kilter mid-March 2020 with the official arrival and acknowledgement of COVID-19 as a global threat in the United States. It was upon us and as with any stressful event, many birthworkers, myself included, walked through the stages of grief in regards to the pandemic.

First Stage Denial: Surely this wasn’t really a thing, was it?

Second Stage Anger: I felt anger acutely as a doula. The restrictions on birth support hit me in the gut and I’m not ashamed to admit that initially I took it as a personal attack on doulas. Of course, I have since come to my senses and understand that at the heart of the decision by hospital administration was to keep everyone safe, including doulas, which brings me to the third stage.

Third Stage Bargaining: Birthworkers explored how to continue to offer birth support, even if virtual, and they pivoted to accommodate the needs of their clients through FaceTime, Zoom, text, and phone.

Fourth Stage Depression: Depression was in there too, and lingers today for many of us. As doulas, we yearn to be with our clients, sharing their birth space and offering physical support in their presence. It pains many of us when we are separated from our clients during birth. It’s truly a struggle that hits a doula right in the heart. And finally, we
encountered acceptance.

Fifth Stage Acceptance: COVID-19 will remain in our midst for awhile and have far-reaching implications on how births will look for the foreseeable future. It is our new, indefinite normal, restrictions, masks, hand sanitizer, and all.

Acceptance is unacceptable.

Doulas and birthing families have had six months of processing the restriction of doulas from physically attending births in the hospital setting. It’s time to push more aggressively to reintegrate doulas in-person at birth. If you are a birthing parent, I implore you to advocate for your doula, and for all doulas, to return to the hospital. Doulas should be
permitted to attend in person because it is the right of every laboring woman to have support, but also because the research is extensive proving that the continuous labor support doulas provide improves birth outcomes. Doulas help everyone, including the staff and care providers! In fact, reputable birthing organizations such as The Association of
Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) have made statements early on defending doulas as essential members of the birth team, and encouraging them to be permitted to continue to serve in person DURING the pandemic. (https://awhonn.org/covid-19-archived-updates/)

Advocacy: So what are we to do to affect change in hospital policies? There needs to be a push from the birthing parents to hospital leadership. Contact the manager of the labor and delivery unit, and the administrator of the hospital. Make a phone call. It’s harder to ignore a voice on the line. Follow up your phone call with an email and a letter. Paper trails are also hard to dismiss. If there are other hospitals who have allowed doulas to return, be sure
to mention them as well. In Hampton Roads at the time of this writing the only hospitals permitting doulas to attend births alongside the primary birth partner are: Sentara Leigh, Sentara Obici, and Sentara Williamsburg. And don’t forget to express your wishes with your provider. Not just one, but to each doctor and/or midwife at every appointment.

This needs to come from the birthing families, not the doulas. The amount of research in favor of the presence of a doula is dizzying. And the number of statements by various obstetric, nursing, and birth organizations is compelling. The evidence is there and the need is higher than ever. What’s lacking is the advocacy for the presence of doulas during the pandemic. I have compiled some links in an effort to cut down on your need to research data. You will find them at the end of this post. Feel free to use any or all that you see fit. And write those letters, send those emails, and make those phone calls. The change must begin with the birthing women. Not the doulas. We believe in you and we support you. Be an advocate not just for yourself, but for all birthing families.

Below are some links to incorporate into your letters/emails/calls campaigning for the reintegration of doulas to attend births in-person. They are particularly timely and relevant since the statements were made in March 2020, right as the pandemic was taking hold in the US.

Cochrane Database Evidence that continuous labor support may improve outcomes for mom and baby:  https://www.cochrane.org/CD003766/PREG_continuous-support-women-during-childbirth

AWHONN Position Statement for Continuous Labor Support for Every Woman: https://www.jognn.org/article/S0884-2175(17)30482-3/pdf

ACOG (American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine’s joint document on the Safe Prevention of the Primary Cesarean Delivery: https://www.acog.org/en/Clinical/Clinical%20Guidance/Obstetric%20Care%20Con sensus/Articles/2014/03/Safe%20Prevention%20of%20the%20Primary%20Cesarean%20Delivery

ACOG Approaches to Limit Intervention During Labor and Birth: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth

March of Dimes Position Statement on Doulas and Birth Outcomes, January 30, 2019: https://www.marchofdimes.org/materials/Doulas%20and%20birth%20outcomes%20 position%20statement%20final%20January%2030%20PM.pdf

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Birthing Language by Tara Thompson, BWI Birth Doula Student

Words are powerful, so it is important to consider what words to use around a laboring mom. Her senses are already elevated and she is on high alert, and she is perhaps now in her “primal brain”. What is said to her or in her presence is sure to have an impact on her labor and possibly even her labor progression. Words are not always necessary at birth, and even kind and encouraging words may inhibit the mother from fully being in her labor state of mind which could possibly interrupt her labor. Not all women enjoy listening to others during their labor. It is important to know when to talk and when not to. When language is needed or wanted, how we talk is of great importance. Please allow me to explain this further.

The volume at which we speak should be considered. Is the mom vocal herself, perhaps moaning loudly? Is the room full of distractions? Are you trying to assist her in finding something to focus on? She may appreciate a loud, direct tone, but often, I think it is more so the case that a woman needs a soft voice spoken to her. A whisper in an ear can be received stronger than a yell. The loudest voice in the room isn’t always the most impactful. It is important to evaluate the situation, know the mother and follow your intuition when deciding on how to speak to the laboring mom.

Where we are when we are talking to mom is also important. Are we across the room or are we near her and close to her in her laboring space? Depending on where a woman is in her labor, she may only be aware of the bubble around her. To properly communicate with a laboring mom, you must be near her and in her space, while being respectful of that space as well. It is hard to whisper across a room to someone who may not even see or feel you.

Once respecting the importance of volume of our voice and location of ourselves in relation to the mom, we must carefully craft our words. As a doula, I am careful to not interrupt a mom’s labor as sometimes silence is needed and wanted. With that said, I also know when to use words to encourage, reassure, inspire and affirm. I would not want to mislead her by using arbitrary words. I must also be careful to not give subjective medical advice if she asks
questions on what she should do if given options by her provider. These words could easily derail a mom from her labor.

A carefully crafted sentence is important and how we phrase what we are trying to convey to mom should be considered before speaking.
Nurse: “You are 4cm dilated.”
Mom: “JUST 4cm?!”
(insert pause to think, consider her feelings and gently touch mom while looking at her)
Me: “You are making great progress! Your body is working to open so your baby can
come out.” (Refrain from analyzing numbers)

In that exchange of words, I wanted to be careful not to mislead her. I didn’t want her to feel as if she had so much more to progress, but I also didn’t want to convince her that the next part of her labor would be fast. I simply wanted to support her by giving her well-earned credit for her hard work and remind her that her cervix is not a crystal ball.

“This is hard!”, says the mom. My reply would be simple, “…and you are strong! You are doing good work to meet your baby.” I would be careful not to choose words that give herself doubt. I want her feel confident herself. Labor is of course hard work, but it would not be helpful to affirm that or remind her. What would be helpful is to remind her that she is strong enough to birth her baby.

What if mom says, “I can’t do this.” I can recall saying this when in labor with my first. I also remember hearing, “You have to, sweetheart.” Maybe the reply was said with empathy and some endearment, but it did not leave me feeling confident, positive or optimistic. I felt helpless. A better reply would have been, “…but you are already doing it. I am right here with here with you.” I think it would have been helpful to be reminded that I was doing it and that I
wasn’t going to be alone.

These are several examples of what can be said to a woman in labor, but ultimately it is important to remember the timeliness of our words, the volume at which we say those words and where we are communicating them from. If we remember to speak from our hearts, we are more likely to speak what is perfect at that moment in time.

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Together With Love at an Unassisted Birth by Jules Baird (BirthWorks Doula Student)

“She's coming, she's coming, she's coming!" exclaimed the birthing mother.
"Your body and your baby clearly know exactly what they are doing. We are here with
you," I responded as her doula.

My name is Jules. I live down here in Christchurch, New Zealand and have recently
attended my first two births as a Doula in training with Birthworks International. In my
first birth as a doula, I was welcomed and encompassed by the beautiful home birth
midwives and able to support my friend to have an empowering calm home birth.

My second birth was just a month or so later with a mother having her fourth baby and
with a history of fast births. Her second child was a planned home birth with a midwife
after a traumatic hospital first birth. The baby arrived on the bathroom floor before her
midwife arrived. Her mother in law was present and all were well but it was a scary
experience for this mother.

She was able to have a slower calm, attended water-birth with her third in her living
room. Now, her fourth pregnancy was a surprise and caught mother and father off
guard. For them, it took many months to come to terms with having a fourth unplanned
child. I met her late in her pregnancy when she had injured her ankle and was left
mostly immobile. We formed a strong connection over several visits and I noted her
main fears were to be alone during birth and to have an injury due to a fast labor.

The day came. I answered my phone at 2:50am to a very calm positive voice saying,

"I think the baby is coming."
“What’s happening?” I asked.
“I’ve been contracting for half an hour and my water just broke. Yes, come!”

Even though her tone was very calm and relaxed I took her call for me to come very
seriously and got to her house 15mins later (thankfully she lived very close).

Walking in, I heard the mum on the phone saying to her midwife,
"Ok,...I suppose I will call you back when I really, really need you here.”

She sounded slightly dejected. I greeted her husband who was busy in the kitchen
boiling water and beginning to fill the pool. I rounded the corner to greet mum with a
smile as she rolled onto her knees on the couch as a very strong contraction began.

"Wow this is very, very strong...this is the first one like this...maybe I do need to call my
midwife back," she says through some low primal groans.

Her body seemed to shift gear as soon as soon as I, her support person, arrived. I
applied back pressure through this contraction and when it has passed I asked,

“Would you like me to dial your midwife or shall we wait for one more contraction?”
“Wait for another contraction,” she decides.

Moments later, the next contraction came, even stronger than the last one. We move
through this contraction together and then she dials her midwife. As she does I look and
see the pool is a long way from full so I quickly take a hot water bottle, fill it and wrap it
in a clean towel to support her with heat ( a decision that turned into a small miracle
later on, from a carer’s perspective).

The next contraction was stronger again and with a panicked voice and low grunting this
beautiful mother moved to the ground on some clean towels her husband and I lay out
and said,

"She's coming, she's coming, she's coming!"

Mindful that too many words keep a mother in her higher cortex, I wanted to find a way
to validate her fears and calm her in the same moment. So choosing my words very
carefully I said in a soft warm tone,

"I know you don't want your baby to arrive before your midwife. Know that your body
and your baby clearly know exactly what they are doing. We are here with you."

With that, she seemed to calm slightly and go inward finally joining her baby on the
journey to her. Her baby was clearly moving very fast and mums breath was very quick.
Miindful that she was worried of tearing due to a quick labor, I then said in a calm voice.

"Let’s just slow things down a little by slowing our breath," and I breathed slowly with
her.

With that, she really slowed and became calm and present as her baby began to crown.
But just then, another moment of worry emerged from her,

"Who will catch my baby?" (as she was on all fours and didn't want to move).
"Dad is here ready to catch your baby," I said giving him a big “I’m here to support you
too nod" and showing where his hands needed to be.

He watched his daughter’s head be born and slowly rotate. I sensed a moment of worry
from him that he may not be able to catch his baby so I put my hands down well below
his to show him support and reassure him (although for me I had already made a
mental note to myself that I would do everything possible to not touch her baby as that
is not my role and furthermore wanting to protect the microbiome of this little one).

A moment later their beautiful little girl slid out into her father’s hands and I helped talk
mum through carefully lifting one leg so dad could pass baby under to her. I moved

closer to mum as she sat back and brought her baby up to her chest with the most
beautiful calm, empowered look on her face. I remember thinking with reverence,

“Wow, birth is just so normal." I was so caught up in the moment!

Then, suddenly feeling responsible to some degree, thoughts came to me,
“Check the baby’s color.”
“Check the baby’s breathing.”
“Keep the baby warm.” I quickly turned to my side seeing a clean towel wrapped in a
hottie. What a miracle!

We wrapped their new baby girl promptly in a beautiful warm towel and laid her on her
on mum’s chest. She was born ten minutes after I arrived and half an hour before the
midwife arrived.

The mother has since told me how empowering this birth experience was for her. She
said it could have easily been just as scary as her second unattended birth but simply
having someone with her that was calm and positive really allowed her to step into the
moment and be present with her baby girl as they began their next journey of life
together.

For me, this birth was one of the biggest divine gifts I will ever receive. It showed me
that both my knowledge of birth and my ability to calmly trust my instincts in the
moment, were enough to significantly support and help the mother, father, and baby to
have an empowering birth experience.

Later in the kitchen the father beamed saying to me,

"I can't believe I delivered my daughter!"

As this was my second experience with birth support to date, and a much more close up
one than my first beautiful experience, I did find myself thinking of all that could have
gone wrong later in the day... I have been able to settle on the reassurance for myself
that if anything untoward would have happened we would have worked through that
together in love. The key words that linger for me are “Together with Love.” The birth
was a gift my soul will always remember.

ACED Workshop, California, (postponed – date TBA)

BirthWorks International offers the combined ACED Workshop for Doula plus Childbirth Educator certification in one!

Become Certified as a Childbirth Educator and Doula in ONE Program!

BirthWorks International offers a combined accelerated childbirth education doula (ACED) workshopWould you like to help prepare pregnant women for childbirth and serve as a Doula at births? Then this is a program for you! Come and experience the unique way in which our philosophies are integrated into your training. We believe that all women are born with the knowledge about how to give birth. Therefore birth is instinctive. What is instinctive doesn’t need to be taught. Rather we help women to have more trust and faith in their body wisdom that already knows how to give birth. This is unique, empowering, and transforming in nature.

The BirthWorks International ACED Combo Program has been designed to save you time and money by attending one four-day workshop that satisfies one requirement for Certification and which is valid towards Certification in both our Childbirth Educator and Doula Programs. All other requirements are home self-study. Fee includes tuition for both programs as well as the four-day workshop.

Women taking BirthWorks classes develop more confidence and have less fear about birth. They receive both an emotional and academic preparation for birth through Human Values training, Pelvic Bodywork (Optimal Pelvic Positioning), Primal Health, Grieving and Healing and more. Classes are interactive and fun. Our Doulas understand hormonal behaviors in birth and can better assist women through a Primal Health perspective.

Includes tuition to both Childbirth Educator and Doula Certification Programs plus the four-day workshop.

ACED Workshop, Medford, NJ 2017

BirthWorks International offers the combined ACED Workshop for Doula plus Childbirth Educator certification in one!

Become Certified as a Childbirth Educator and Doula in ONE Program!

BirthWorks International offers a combined accelerated childbirth education doula (ACED) workshopWould you like to help prepare pregnant women for childbirth and serve as a Doula at births? Then this is a program for you! Come and experience the unique way in which our philosophies are integrated into your training. We believe that all women are born with the knowledge about how to give birth. Therefore birth is instinctive. What is instinctive doesn’t need to be taught. Rather we help women to have more trust and faith in their body wisdom that already knows how to give birth. This is unique, empowering, and transforming in nature.

The BirthWorks International ACED Combo Program has been designed to save you time and money by attending one four-day workshop that satisfies one requirement for Certification and which is valid towards Certification in both our Childbirth Educator and Doula Programs. All other requirements are home self-study. Fee includes tuition for both programs as well as the four-day workshop.

Women taking BirthWorks classes develop more confidence and have less fear about birth. They receive both an emotional and academic preparation for birth through Human Values training, Pelvic Bodywork (Optimal Pelvic Positioning), Primal Health, Grieving and Healing and more. Classes are interactive and fun. Our Doulas understand hormonal behaviors in birth and can better assist women through a Primal Health perspective.

Includes tuition to both Childbirth Educator and Doula Certification Programs plus the four-day workshop.

ACED Workshop, Medford, NJ 2017

BirthWorks International offers the combined ACED Workshop for Doula plus Childbirth Educator certification in one!

Become Certified as a Childbirth Educator and Doula in ONE Program!

BirthWorks International offers a combined accelerated childbirth education doula (ACED) workshopWould you like to help prepare pregnant women for childbirth and serve as a Doula at births? Then this is a program for you! Come and experience the unique way in which our philosophies are integrated into your training. We believe that all women are born with the knowledge about how to give birth. Therefore birth is instinctive. What is instinctive doesn’t need to be taught. Rather we help women to have more trust and faith in their body wisdom that already knows how to give birth. This is unique, empowering, and transforming in nature.

The BirthWorks International ACED Combo Program has been designed to save you time and money by attending one four-day workshop that satisfies one requirement for Certification and which is valid towards Certification in both our Childbirth Educator and Doula Programs. All other requirements are home self-study. Fee includes tuition for both programs as well as the four-day workshop.

Women taking BirthWorks classes develop more confidence and have less fear about birth. They receive both an emotional and academic preparation for birth through Human Values training, Pelvic Bodywork (Optimal Pelvic Positioning), Primal Health, Grieving and Healing and more. Classes are interactive and fun. Our Doulas understand hormonal behaviors in birth and can better assist women through a Primal Health perspective.

Includes tuition to both Childbirth Educator and Doula Certification Programs plus the four-day workshop.