The role of a doula and "scope of practice"
I am frequently asked as a midwife attending homebirths about hiring both a midwife and a doula. Is it necessary? The answer? Yes and No. I will explain....
To understand the need, you also need to understand the unique roles of each. There is an overlap of roles with a midwife as a support person but also many differences.
When I served women in south Georgia, I midwifed women during homebirths, I also taught childbirth classes, had a monthly breastfeeding support group and I took doula clients who were planning a natural hospital birth. I was DONA trained and certified. So, I know a bit about the subject!
As a midwife, we spend a LOT of time each month during prenatals. This gives us the luxury of time to educate our clients on many topics. We begin to build trust between us as to the kind of birth the mother is hoping for and the midwife’s practice style. I’m a firm believer in informed consent, truly informed consent and if I feel strongly about something, I usually spend the time with my client to help them understand the reasons why I feel something may be important, especially in their own unique pregnancy or circumstances. But, ultimately each client and family must take responsibility for making their own choices. Education is certainly a huge factor in the midwife/mommy relationship!
During labor itself, the midwife doesn’t always arrive at the very beginning of labor. First time moms especially may feel the need for assistance with coping measures before we might arrive. A very experienced doula can not only help during that time but also be more in tune with the rhythm of labor and help us know when we need to be heading in your direction. I strongly encourage couples to seek out a good childbirth class during pregnancy. At these classes you will learn about labor and birth, the vocabulary unique to this event, coping measures, breastfeeding techniques and newborn care. They are invaluable to first time parents and even experienced parents who are attempting natural birth for the first time.
Can a midwife support a mom during labor? Absolutely! It is part and parcel of what we do but it is not the only thing we might be doing. Women during labor sometimes develop a ritual that becomes near and dear to her. It is something she does during every contraction that helps distract her and sometimes they can be quite funky and unusual but they are all hers! It may involve standing draped over someone’s shoulders and gently swaying back and forth or it might be making a fist and pounding something (or someone!). It might involve having someone pour a cup of water over your belly in the pool or making low moaning sounds. She might need someone to press their fists into her low back with every contraction or she might insist that someone brush her hair or rub her head. Or she might want everyone to back off entirely and don’t touch her at all. Whatever works! Sometimes the midwife or one of her apprentices can be involved in this process, but we are also greatly involved in other things too, so there may be times we aren’t as available for support as you may feel you need.
During a birth, it is the midwife’s role to be involved in the safe arrival of mother and baby at the end of this journey. Sometimes we are setting up equipment, sometimes we are charting, sometimes we are taking maternal vital signs and sometimes we are listening to baby’s heart rate, both during and between contractions to see how your little one is handling labor. At times, we may check internally to see if cervical changes are happening or if baby is malpositioned in some way that may be prolonging labor or making it more uncomfortable than it should be. Sometimes we are thinking of things we could suggest that may help the baby rotate into a more favorable position. We are keeping up with making sure mom empties her bladder often and staying hydrated an nourished. We are aware of mom’s energy level and concerned with finding a balance between rest and active labor and progress. We are always focused on making things more comfortable for the mother and keeping her and the baby in what I love to call the “normal box”. At times, it simply involves creating a safe space for her to labor unhindered.
If a labor is long, many women really need extra support people. These are the women who come around you to support you and help meet your needs. A trained and experienced doula can be a perfect addition during times like these. Sometimes a husband who really cares and is sensitive to your needs may be all you need. But even a loving husband may need a meal/potty/nap break in order to keep going. And some husbands may choose not to be as involved as others.
If you desire to hire a doula for your upcoming birth, you may want to understand a few of the parameters of their scope of practice. Remember that the training for doulas and midwives is QUITE DIFFERENT. Becoming a midwife is a much more involved process in education, training, apprenticeship and experience. A midwife is responsible for two lives. A doula is responsible for emotional, physical and psychological support during labor.
A doula does these things:
1) She may take on the responsibility of prenatal education, especially if a client hasn’t taken a class.
2) She will probably spend time talking to you and helping you learn some techniques for coping during labor. If she is good, she will probably spend some time getting to know YOU and what might work best for you.
3) Especially if you are planning a hospital birth and working with a caretaker who is not very natural birth minded, she will help explain all the interventions you may be offered during labor, helping you sort through the pros and cons and necessity of each of them. If she is honest and balanced, she will admit there are times when those interventions can be life-saving or necessary but she will help you be fully informed so you can decide for yourself.
4) She may help you formulate a birth plan that is evidence based and help you to understand that sometimes birth takes a path less traveled and you need to be prepared for Plan B :)
5) She will come alongside you during labor, giving you whatever kind of support you need to help you achieve your goal. If your spouse wants to be involved, she will come alongside him also, making an even stronger support system, at times suggesting things to help, at times replacing your partner so they can eat, rest or take a potty break.
6) If your labor lasts for longer than a certain number of hours, your doula may have a backup agreement with another doula to replace or relieve her for some rest. Ask if she has this kind of agreement in place and make plans to meet the substitute.
7) Your doula should be available for you throughout labor, birth and immediate postpartum care. If she leaves before the placenta is delivered or breastfeeding is established, she has failed to finish the job. I was trained in assisting moms with breastfeeding as a doula and this is part of the job. In a homebirth, there may be different expectations for a doula. She may be the extra pair of hands that helps you get safely out of the birth pool and into a shower or bath after the birth. She might stay with you to make sure you aren’t lightheaded and pass out. She might hold the baby while the midwife deals with third stage with the mother. She might accompany the mother to the hospital in the event of a transfer of care during any stage of labor, including a postpartum hemorrhage. She might help tidy up after a birth or scramble some eggs for mom’s first meal after the birth. Ask her how she adapts her care from a hospital birth to a homebirth to see if this is the right person for you.
Doulas have a definite “scope of practice”. Many of the certifying agencies have very specific things they are allowed or not allowed to do to protect them, protect their clients and to safely stay within those guidelines. Remember that while a professional, certified doula is knowledgable about childbirth, she does NOT have the training in decision making, diagnosis or crisis management that are required of a midwife or obstetrician.
A doula should never.....
1) Perform any medical, homeopathic or even “natural” treatment on you prenatally or during labor. She might not be aware of your total health picture or issues. A doula should not suggest induction methods. To do so is to take on the role of the primary caretaker and the responsibility for your health and safety. In a homebirth situation, it may result in your midwife needing to be in two places at once, or to attend a birth in an exhausted state because of another long birth. I rarely interfere with the timing of a birth unless I have a REALLY GOOD compelling reason to get the baby here sooner rather than later. So having a doula take on that responsibility is completely out of her scope of practice. A more appropriate response to help a mother, would be to say, “There are some natural remedies for indigestion (induction, constipation, group beta strep, insomnia, etc). Why don’t you ask your caretaker about them?”
2) A doula should not palpate bellies, listen for heart tones, physically manipulate a baby’s position or do internal cervical checks. She should not break your bag of waters. This is NOT within the scope of practice of a doula. This takes more education and experience, especially in the interpretation. There are some women with EXTRA extensive training who are a monitrice who may listen for heart tones and do cervical checks but they are NOT a doula then. However, even a monitrice should not put herself in the position of attending a birth (on purpose).
3) A doula should not insist that you keep vital information about your health, pregnancy or labor from your primary caretaker. If your doula advises you to keep hidden any information that could help your caretaker make good decisions about your care and the safety of yourself and your baby, they are not doing you a favor and they are NOT operating within their scope of practice. I understand that many times unnecessary interventions are employed in the medical world, but ANY caretaker who is in the place of having responsibility for you should be fully informed. Ask them to help you understand their reasoning or criteria for their intervention. Remember that if the intervention is not evidence based, you have the right to say no. In homebirth, hopefully you have chosen a caretaker whose practice style lines up with your philosophy of birth. This is not an adversarial role. We have usually spent months working on this relationship of trust, and homebirth midwives practicing the midwifery model of care are low intervention caretakers anyway.
4) Doulas should not contradict the primary caretaker in matters of life and death and in crisis situations where minutes count. I have attended a lot of births and have a lot of experience with babies that sometimes get malpositioned. Doulas have training too in helping moms seek positions that can help move a malpositioned baby down or help them rotate. As a rule, I let the doula experiment with different positions to see if they will help because sometimes you never know which one will do the trick with that particular mom or that particular place in her pelvis that baby needs to maneuver through. However, there are times when I do an internal exam on the mom and notice exactly how that little head is positioned in there and what effect it is having on the cervix at that moment. I may recommend that the momma try a certain position based completely on my findings in the internal exam and what needs to happen. A doula who insists on something totally different at this point when I have made a specific recommendation is not helping you to achieve your goal. At any point in a labor or birth where there is a life-threatening situation (like a shoulder dystocia, hemorrhage or need for resuscitation) there should only be ONE person in charge and directing the mother and others in how to proceed, and it should be the midwife.
5) A doula should never tell you that there is no need to head to the hospital if you would rather stay home and just have the baby there (if you are planning a hospital birth) or tell you don’t bother to call the midwife for a homebirth. You might be just fine. But you might not. Is your doula listening to heart tones and knowledgeable about how to interpret what she is hearing? Can she properly estimate blood loss? Does she know how to deal with maternal shock? Taking and interpreting maternal vital signs? Does she suture? Does she have the equipment, knowledge and experience to handle newborn resuscitation, handle a hemorrhage, shoulder dystocia? Can she do a thorough newborn exam and say for certain your baby is transitioning normally and has no problems? Can she deal with a placenta, especially one that may not be releasing? Would she know if you had retained fragments or membranes or be able to do a manual removal of pieces? If she has the equipment and knowledge for all this, then she isn’t a doula any longer. She is practicing as a midwife. That is NOT in the scope of practice of a doula. Two birth families in the Atlanta area have lost a baby due to a doula who insisted that it would be “just fine” to stay home and deliver at home with her alone. This should never happen.
6) A doula should not be a mom’s voice. She is an advocate, an advisor, an educator and a support but she should never take over the role of the mother’s own voice. She can help the mother make informed choices and choose a caretaker that is best suited for the kind of birth the mother is working towards. But a doula should always remember that it isn’t HER birth. It is the mother’s birth. The mother has to take responsibility for her own choices. There were times when in the role of a doula that I wanted MORE for the mother than she wanted for herself but I had to remember that this was HER birth, not mine.
When a trained doula fulfills her specific role, she can be an invaluable member of the birth team and help the mother through her birth journey. She can be very helpful to me in my own role as the midwife because she can support the mother before I arrive and during times I am focused on other duties. She can help a mother stay focused on her task and achieve her goals. She can be one of many voices that keep reminding this mom that she can indeed birth! But we always need to remember not to ask her to operate outside her scope of practice or to be wary if that happens. If moms have questions or concerns, I prefer they contact me as their primary care provider. I do not want to put a doula in the position of making medical decisions or diagnosing possible complications during pregnancy or labor.