Tuesday, August 10, 2010

The "Can do no Right" Doula Blues

We have talked about the phenomenon of "doulas behaving badly". I have brought up a few things about doula work to try to help us be understood a little better by medical professionals. Now I wanna sing the blues. The truth is, more often than not, doulas who behave conscientiously still get their share of berating. It's true that those who behave badly can create or exacerbate prejudice for our work, but the reality remains that sometimes we're hated on sight simply because of who we are. Our very presence does tend to evoke thoughts of "Are you here to challenge my authority?" in some caregivers. But instead of asking questions or trying to come to a place of understanding, what can happen are knee jerk reactions. Personal attacks, even. I have beseeched doulas to do their part in playing nice and have explained the nature of our work so caregivers will hopefully feel a bit more at ease with us. This doesn't mean I expect overnight changes. I would like to take the opportunity to vent a little of my sadness. Here are my blues:

If I try to respect a hospital staff member's job by getting out of his/her way, I can be asked huffily, "Why aren't you helping me?" If I jump in and try to help (change bedding, soiled gowns, etc.) I am often criticized for not doing it properly, or told altogether to not interfere.

I have been told, "I know what I'm doing!" when I tell a resident who has just arrived on shift and who is about to take the mother off the monitor for an hour, that the reason she is still on the monitor is because of the fact she's been having unusual bleeding during labour and the last resident said she was supposed to stay on it for a while (I'm just relaying information). Taking this as a strong message to just keep my mouth shut and not assume to inform anyone, I have with the same client been told by another staff member, "If you KNOW she has unusual bleeding, why were you going to let me take her off the monitor? I have visited 6 patients in 15 minutes...if you KNOW the drill, speak up!" Sigh.

When I've removed a bloody pad from the bathroom floor so as to keep the environment clean, I have been told, "You can't move that! I need to measure the blood loss!" When the next time the situation has arisen and I have left it there for the nurse to assess, I have been told, "Why would you leave that there?! It gets germs all over the place! I thought you liked to keep the environment clean? Isn't that a doula's job? Jeesh!"

When I have placed a towel under a standing, nude, extremely actively labouring lady to protect the floor from slippery amniotic fluid, it has been yelled at me, "she's going to trip on that towel..it's a hazard!" When I have not placed that towel down, I am yelled at, "What are you thinking not putting a towel under her? Don't you know that amniotic fluid on the floor is a hazard?!"

When I have been buzzing for someone in a busy hospital to help a 1 hour postpartum lady up to the bathroom to have a much needed pee, I can be asked with scathing indignation, "why wouldn't you just bring her yourself? Isn't your job to tend to her?" And, when I have taken the initiative and just brought the full bladdered lady to the bathroom myself, I have been been told, "You can't take her to the bathroom! What if she faints? I'm responsible!"

If I have shown as much respect for boundaries as possible and asked first before doing anything, I have been advised to stop pestering, to take initiative, and just DO what needs to be done (barring anything considered medical). When I have taken the initiative, I have been told to do nothing without permission.

A doula can be a scapegoat for staff members' frustrations. When things are busy, we can be damned if we do, and damned if we don't. Sometimes it feels like I can just do no right. If that's the way you feel sometimes, my doula friends, let the attitude roll off you like water. Don't take it personally. Sense the tone, and do what you think will cause the least tension. If you're wrong, you can rest assured you at least respected your scope of practice, respected your client, and did your best to respect the staff.

I personally have some boundaries I don't cross, even when asked. I will not "just put the lady on the monitor for me..I have another lady about to deliver and don't have time." I will not start "coaching" and counting during the second stage of labour, unless this is what the mother wants. If a staff member wants to assume I'm lazy or don't know what I'm doing because I don't engage in the Purple Pushing Circus, that's fine. I will not "make" my client stop vocalizing and "get control of herself" even if the whole room is scowling at ME because of my clients' "antics". If she is releasing tension by using her voice and is obviously progressing beautifully, there is no need to change anything. I will continue to just be quietly present if that is what the feel of the labour dictates, not worrying about the whispered comments I hear, "why isn't she DOING anything, like telling her to breathe or anything? Why did they hire her?" I will not be over solicitous to a client to please onlooking staff members by performing sacral counter pressure, spraying lavender, applying cool cloths and asking endless "are you okay?" kinds of questions when I know it's going to get on this particular client's nerves. I will also not answer, for example, if my client is going to take postpartum Synto by IV or injection, as this is not a call a doula should ever be asked to make. Yet we're asked to speak for our non-communicative clients all the time. I will communicate preferences the client has discussed with me, but I will never speak for her concerning a split second medical decision!

And yes, sometimes I do get eyeballs rolled at me when I gently say, "I'm sorry, but I can't speak for my client." Just like I get eyeballs rolled at me when I offer important information about my client that was not asked by the staff, because I'm not supposed to "speak for" her (ex. "Mrs. P had a double mastectomy 4 years ago..she has asked me to communicate that she wishes not to be asked if she will be breastfeeding").


I just continue to smile and be kind, trying not to get caught up in the criticisms and comments. When my clients hold their babies in their arms with huge smiles on their faces and tears in their eyes, shining with gratitude for everyone in the room having been there for them how they needed them to be, this is all the "reward" for my efforts I need. I have surrendered the need to please everyone on a hospital staff and invest huge efforts in having them like me and approve of my work. You can't please everyone. I serve my clients, and am confident I do nothing inappropriate to endanger them. I respect all boundaries to the best of my abilities, and do my best to reduce tension. And yes, it does burn sometimes. I do so much work to be the most diplomatic and conscientious person in the room (as do the vast majority of doulas), though there is not as much pressure on caregivers to do so at all, thus FAR more occurences of challenging medical staff behaviour than actual bad doula behaviour (such as non emergency episiotomies done without explanation or consent, or the undermining of a woman's desire to have a natural birth "you think it hurts now? It only gets worse. Are you SURE you don't want your epidural now? Anesthesia is on the floor." or, upon vaginal examination the incredibly insensitive "hmmmm, it's pretty tight in there...I HOPE this goes the way you want, but, hmmmm.I don't know...how tall are you and what's your shoe size?") I know these actions and comments are not intended to hurt, and most likely they are intended to spare a woman from perceived potential harm or disappointment if things don't work out the way she wanted. In fact, though, the tone of these comments is disempowering, and women need to stop being infantalized. A doula knows that a lady is more apt to be able to handle an honest trouble that arises, but will be far more disappointed if she felt not believed in from the start with these misguided attempts to "protect" her heart from getting its hopes up. This paternalistic type of protection so often creates self fulfilling prophesy through the oxytocin killing stress it introduces into the room.

If I am at a birth and someone takes me aside and says, "why aren't you letting this mother get an epidural? Can't you see she's suffering enough? Why would you be so cruel as to encourage her to keep going with her labour when clearly she is in agony? Have you been feeding her garbage about how epidurals are bad?" I just smile and explain that an epidural is a mother's choice, not ours to make for her, and that she will most certainly have our support if she asks for one. When I'm with a woman who TRULY wants an epidural, there's not much I could say to stand in her way from getting it, even if that's something I WANTED to control. It's pretty crazy, really, when you think about it: at the same time as being thought of as puppet masters who have omnipotent powers to pull all the strings and have all control over a woman's attitude, sounds, movements, breathing, requests, bodily functions and choices, we are often not thought of as smart enough to even hold a vomit bowl competently. I am reasonably well known and familiar in the hospitals I go to, and have the reputation of being a respectful doula. But if I run into a staff member I don't know, enough times that it ends up being quite hurtful, I feel like I'm guilty until proven innocent. This is why I apprentice my trainees: so they can become a little acclimatized to the environment before their dreams of going off into the hospital and building bridges and making friends are dashed at the first harsh comment or judgement. It is good for them to know that this is a challenge that will remain with them perhaps even after 17 years of good practice.



Someone needs to make a decision. Is it our "power over our clients" and our seeming omnipotence that is perceived as dangerous, or is it our stupidity and ineptitude that endangers, as we are, after all, just a bunch of hippie moms? Do you really think we could magically stop a woman from demanding an epidural she really wants one? Do you really think our clients are so malleable and uninformed that they'll put all their clinical decisions into the hands of a DOULA? We just translate the information that's said in a more nurturing way and open the doors for more questions and options. Why is it seemingly believed that when clients speak up for themselves it's because we doulas are playing ventriloquist in the corner, in a voodoo like way using our labouring ladies to promote our agendas and personal beliefs? If we ask questions that any well informed consumer of maternity care may ask (ie: what are the benefits vs. the risks of her taking Synto at this point? Is it possible an epidural in this case could slow down/speed up labour?), it's because we have been asked by our clients to do so to help them gather as much information as they can about their care. In labour, they are busy trying to have their babies, and may not be in a logical state to pose these questions, the answers to which they most likely already know, as most of them read a lot, but aren't in the headspace to think about unless things are presented plainly.

And if we're so stupid and inept, not jumping in to do all the stuff everyone knows doulas are "supposed" to be doing every moment, like double hip squeezing until the cows come home, or doling out ice chips, and asking "dumb" questions of our clients like, "are you comfortable pushing on your back like this? Is this the position you want to be in?" why on earth are we sometimes asked to put a mom on a monitor or handed a bowl of warm water and stack of compresses and told, "just tell us when you see the head." I'm not kidding, I have been asked to do these things. I'm often asked how dilated my client is when I show up to the hospital! I'm a doula so I DON'T have to assume this type of responsibility, thank you very much.

Let's just debunk these misperceptions altogether. I am neither omnipotent nor stupid. I'm a doula, and my work is important. Klaus and Kennel and many others have done studies on the amazing reduction in unnecessary medical interventions, better overall infant/maternal health, and greater satisfaction with birth and breastfeeding, that doula care can provide. So evidence states that IN FACT good doulas (not those few doulas actually behaving badly) are the opposite of dangerous. And I have to say, IN FACT, most of us ARE good doulas. Just as most medical caregivers are good. Prejudice and/or misunderstanding from some medical caregivers that can turn anything we say and do into an outrage because our very presence "threatens" status quo in the hospital is as likely to be a reality as an actual bad doula behaviour. "No matter what you do, somebody always 'knew' you would".

Perhaps this fear of us having the potential to make everything SNAFU in the hospital maternity ward is not actually a testament to our dangerous, witchy natures, but simply a fundamental resistance to the uncharted waters of that unfamiliar, radical thing our clients often want and we support called normal physiological birth! That's right, no bells and whistles like nifty beds, prophylactic cuts for postpartum healing enjoyment, constant monitoring, restricted food and drink intake, imposed positions, prescribed pushing formulas, silly jokes right after the baby comes out instead of reverent silence...and yes, they want it in the hospital because they appreciate the potential for swift and skilled intervention...when necessary. They want to have their cake and eat it too, and why not?

Putting doulas in their places because they've been perceived as being uppity, or sabotaging us by telling us one day something we do is wrong and then the next day the opposite thing we do is wrong too doesn't hurt doulas (permanently, anyway..we're used to it, and have thick skins), but the birthing women themselves. The birthing room is no place for a pissing contest.