By Kim James, BDT(DONA), ICCE, LCCE
As a childbirth educator, birth doula, birth doula trainer and owner of DoulaMatch.net, I hear a lot of birth stories from parents about how their doula’s support made a world of difference. More infrequently, I hear stories about doulas who missed important opportunities to provide emotional support, leaving families wondering what exactly they paid for.
Here are two stories that illustrate the pitfalls of under supporting the earliest parts of labor and suggestions for how to respond well to our clients’ emotional needs, even before labor begins.
Story #1: “She never really showed up for us.” In this story, the client signs a contract that states the doula will arrive in time to provide support in “active labor.” Once labor starts, the clients call their doula to let her know contractions are 5-10 minutes apart. The doula responds saying that labor is likely still in the latent phase, and they should call her 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 woman is close to pushing. The parents feel the doula provided little support other than to pop by the birth, take a few pictures, admire their baby and leave soon after breastfeeding was established. The doula feels she followed the letter of her contract, and that the parents should have called her earlier if they wanted her physical presence.
Story #2: “We didn’t end up needing her.” The client’s water breaks before labor starts. She calls her doula to let her know they are heading to the hospital as per their physician’s instructions. The doula tells her clients to call when they need her. At the hospital, the clients, along with their providers, decide to induce labor. At each decision point during the induction, the clients let their doula know via text message. The doula always responds with a “when you need me, let me know” reply. After 12 hours, she stops receiving texts from the clients. The doula texts 24 hours after her client’s admission, to find out how they are doing, and discovers they received an epidural and gave birth several hours earlier. The doula is stunned her clients did not call or ask her to come provide support.
So what happened in these stories? The doulas in each story weren’t able to recognize their clients’ emotional needs and missed key opportunities to provide support during the earliest parts of labor. The ways our clients remember their early labor and how we respond to their communication at that time can set the tone, as well as shape their perceptions of and the actual outcome of the rest of the labor support we provide.
Let’s break down the stories into best practices for supporting our clients during the earliest parts of labor.
1. 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[i], 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 five centimeters for multiparous parents and six centimeters for nulliparous parents. The active phase of labor simply marks the acceleration of cervical dilation. As doulas, it can be a mistake to tell clients our support will begin when labor is “active.” While that may sound reasonable to parents during a prenatal interview, and clients may agree when they sign your contract, the reality is that most parents need emotional support well before the onset of active labor. It’s important for doulas to recognize and respond to their clients’ need for emotional support regardless of what phase of labor the client is in.
2. 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 parents that she had several appointments on the same day, and that she’d rather not miss these commitments if labor wasn’t “serious yet.” The other doula only communicated with her clients via text, which means that she didn’t get to hear the worry and concern in the clients’ voices as they headed into the hospital and a possible induction. When our clients contact us, they pass along information they think we should know. From our perspective, that information is only half the story. We need to understand the other half, as well – our clients’ emotions and feelings. The best way to do that is a phone call. When your client texts or emails letting you know something is up, always strive to hear their voice. Pick up the phone and call, or text them back and tell them you’ll call them shortly. When you do, acknowledge what your clients have told you in the text or email and ask clarifying questions. Find out what your clients are feeling and how they are coping. 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 will be in contact next.
3. Intuit your clients’ 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 but seems unsure of what to expect, I suggest 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 be able to see and hear how your clients are managing their early labor contractions. Based on this, you’ll be able to provide the reassurance they need, along with suggestions for comfortable positions and strategies for rest, nourishment and distraction. You may not end up staying with your clients more than an hour or so, but your physical presence may be just what they need to bolster 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.
4. You go when your client goes. Whenever your clients goes to their hospital or birth center, for whatever reason, offer to accompany them. Think about the client in the second story, whose water breaks before labor starts. Inevitably, your client in such a situation will be directed by her medical provider to go to the hospital to assess the event and baby’s heart tones. At the hospital, recognize that part of providing support means supporting your clients’ ability to self-advocate by helping them know what questions to ask when important medical decisions come up. While your clients may feel they don’t need emotional support at this time, we know differently, that any time clients arrive at their birth place, there will be a myriad of decisions to make and accompanying emotions to support. Gently offer your physical presence. Perhaps say something like, “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 the early decisions that ultimately decide the route and outcome of your clients’ births. Don’t miss this opportunity to help your clients ask questions about their care, acknowledge and process their feelings, and help them make confident, comfortable choices with their medical care providers. Go when your client goes.
5. Inductions are special. We know 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 to 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, help them settle in, assist with asking questions about expected timelines and outcomes of proposed induction methods, and ensure 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 not stay for the whole 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 cited above. If your clients are managing well, and if contractions are not present (yet) or are still very mild, it may not be necessary to stay. 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 route or outcome 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.
[i] 2014 ACOG Revitalize Obstetric Data Definitions (Version 1.0) https://www.acog.org/-/media/Departments/Patient-Safety-and-Quality-Improvement/2014reVITALizeObstetricDataDefinitionsV10.pdf?dmc=1&ts=20160225T1350295036
Kim is the DONA International Washington State Representative, as well as a birth doula, birth doula trainer and childbirth educator in Seattle, Washington. Kim is also the owner and operator of www.DoulaMatch.net
Yes!!! To all of the above. I love it when my patient has decided to get a doula on board. I often end up asking where she is. Invariably I hear they didn’t want to bug her because it’s 2am or they weren’t sure they were in labor or she said she’d be there later or even went home for a nap. Especially – especially!!! during long prodroming labors that don’t necessarily require hospital admission it is so helpful to know that my patient is home with a doula that helps her relax and not despair and encourages her. And inductions. Yes! Everybody eventually feels like giving up but with a doula at her side my patient will feel more supported and understand that it is normal when things move slowly.
Thanks for writing this!
I completely agree that the doula plays an important role in early labor, and the doula’s physical and emotional availability during this time sets the tone for the birth. That stated, I do feel that the article does have a somewhat unfair and unrealistic expectation of the doula! Inductions can easily take 2 days from start to finish. Most of us don’t live a hop, skip, and jump away from the hospital. It is usually not realistic for a doula to check in on her client at each of the induction points mentioned above.
There has to be a balance where the doula is emotionally and physically available for the client, and yet does not need to show up for the beginning of perhaps a multi-day induction. (And once she comes to the hospital… how likely is she to leave?)
Yes! My doula was certified through Dona and I kept pleading with her to come meet me. She kept delaying. By the time she finally arrived at the hospital, I wondered why I hired a Doula in the first place. A
I agree with article. Re inductions l show up when my client settles in then give a time that l will return and request a phone call..not a text if any change prior to that even if they are not sure l should come in. With.home labor l set up times for calls to talk thru cxs and request client call me if anything at all prior to.that time. I respect dona and they do operate from medical premises. I am dona trained and Well Rounded cerified. I would love perspectives from other doulas on this.
I thought it was interesting that you mentioned how a professional should be able to recognize that their client is in need of emotional support even when they don’t ask. My sister is looking for a labor doula but doesn’t know really how to look for one. I’ll be sure to talk to her about finding a professional who will give her the support she needs when needed.
My wife is a doula and I absolutely support her decision to be one wholeheartedly. She is extremely passionate about her job but the end result of her passion is her spending two and three days with her clients while me and her three kids remain at home don’t you believe there should be some more of a balance so that the mother can have her suppprt but the doula can also still be a wife or a mother…….
I love everything you wrote!!! I’ve been doing all of these suggestions, and have been questioned by some of the nurses, that the other doulas don’t do this with thier clients, so i thought i was doula-ing wrong. So I’m encouraged to know that I’m not. 🙂