By Sharon Muza, BS, CD(DONA), BDT(DONA), LCCE, FACCE, CLE
I am proud to be introducing a new occasional series “Doula Me This!” that challenges doulas to consider how they might handle a birth or postpartum situation, in consideration of their training, experience, professional judgment and DONA International’s Scope of Practice and Code of Ethics. From time to time, I will present a situation and ask you to share how you feel a doula should proceed given the information provided and the role of the doula. There are many times when we must take a step back and assess how we can best serve a client while staying within professional guidelines. The answer at times may be difficult to find, or sometimes easy to identify, but difficult to carry out. It is good to have healthy discussions with colleagues and share thoughts and ideas. I hope that can happen here in our comments section and we can all learn and grow.
Doula Me This!
You have been hired as a birth doula by clients for their upcoming birth. This is their first baby. They have completed their childbirth class series. At 34 weeks, all of you have now gathered for the first prenatal and your client and their partner have shared their birth plan with you. Together you are discussing their birth preferences.
As long as the pregnant parent and the baby are doing well, this family is comfortable waiting until 42 weeks for labor to start, hoping to go into spontaneous labor, avoid any unnecessary interventions, and have a vaginal birth without pain medications. In skimming their birth plan, everything seems “do-able’ and they are not asking for anything unusual or atypical.
You are familiar with their healthcare provider and in fact, recently have had three other clients who have birthed with the same doctor. You recall that your other clients had similar birth wishes and were reassured by this healthcare provider all throughout their pregnancy that everyone was on the same page. When those clients were just shy of 40 weeks, the doctor strongly suggested that an induction be scheduled for their due dates. The doctor was very persuasive, citing increased risk of a stillbirth and had even told the families that “nothing good ever happens after 40 weeks” at the 39-week appointment.
After the 39-week appointments, your three previous clients all agreed to be induced at 40 weeks and after long labors, two had a cesarean for failure to progress and one did squeak by with a vaginal birth but they had an epidural and a long, physically and emotionally exhausting three-day induction.
After these recent experiences with your past clients, you are doubtful that this same provider will continue to support your current clients’ wishes and things will most likely unroll in a similar fashion. You expect that at the 39-week appointment for this family, a discussion about the dangers of remaining pregnant will be had, and a strong recommendation to induce at 40-weeks will be made.
While listening to this family explain the type of birth they are hoping for, you sit and wonder if you should mention to them how unlikely it is that this doctor will be supportive of their wishes as they get closer to their due date. You feel strongly that the three recent experiences you had with this doctor are very revealing about the doctor’s true colors. You might be able to help this family avoid a lot of stress and heartache and some difficult decisions later if you speak up now and suggest they explore other options to be sure they are working with the most supportive provider possible.
What Would You Do?
Doula Me This! What do you do? What do you say? What are your next steps? Share your thought process, actions, and opinions in the comments below. I look forward to a lively discussion and will expect that even if people disagree, we will be respectful of each other and our colleagues’ opinions.
After reading their wish list … AKA “birth plan”
I would mention the OB practice is known to recommend induction at 40 weeks if they haven’t gone into labor. And suggest they talk to their doctor about this policy. Then they get handle the situation without prejudice or the Doula’s opinion.
It becomes neutral information the doula is sharing and clients can speak directly to the OB about that policy.
By informing themselves directly from their provider clients get to make their own decision and evaluation if they’re in agreement with the provider they chose and the policies.
DOULA me this! What a great opportunity to get us thinking about how we can best benifit our clients while staying in the scope of our position, and to hear new ideas from other Doulas.
Thank you DONA!
At this meeting I would not mention her doctor specifically but I would tell her that some doctors may see this as a problem and encourage induction. Make them aware that the outcomes of induced labor my not fit their birth plan. I would suggest that they investigate and I will also to make sure that I give my client all the evidence based information available regarding any dangers of waiting past 40 weeks so they are well prepared. If her pregnancy goes to the point of having this discussion with their doctor, they can make their decision of how to proceed with knowledge and not by being pressured. I course I would support whatever they decide.
Yes, I agree it would be best not to mention the doctor or practice when having the discussed topic with clients.
Even though i am inexperienced, I am going to offer my opinion 🙂 Without referring to the caregiver I would initiate focused and probing discussion around the effects/realities of allowing the pregancy to go beyond 40 weeks so that the client would have more info with which to confront the sugfestion of the caregiver should the situation arise.
As soon as a client mentions Induction, I start sharing past clients experiences. I also discuss the bait and switch dynamic in the medical environment with my clients from the start. So they generally can put 2 and 2 together and take whatever action they deem appropriate. Some switch providers. Some become assertive with the doctor. Some go along with Induction. It’s their decision. I just make sure they have the facts.
Catherine, this is exactly what I do. if I have the privilege of beginning with a couple before 30 weeks, and we have already discussed her wishes, I will be honest about the “bait and switch” tactics, so my client can switch to a more appropriate provider/hospital, should she desire to do that.
YES information is what’s needed and experience is great.
Using evidence based information I would educate the family regarding methods to determine EDD, what is considered full term, the amount of risk in waiting for 42 weeks. I would suggest that if their Ob/Gyn suggests inducing earlier than 42 weeks they be prepared to ask questions and not feel intimidated.
I wouldn’t specify that THEIR doctor prefers to practice an induction about 40 weeks, because in my experience doctors may start to dislike working with you as a doula if you say things like this to their clients. So what I would do, is just speak in general, and say that if their wish is wait an spontaneous labor, they should have a discussion with their care provider (as any other pregnant couple), about his policies and how he handle that situations. Doctors are very clear and honest if you do a direct question, so I would encourage my couple to ask about this kind of things with time, so they realize by themselves how is going to be everything with this care provider. That way they know what to expect and it’s their personal INFORMED decision.
I have found that some careproviders are NOT honest about their preferences even when patients ask direct questions. I have discussed this with the doctors involved (yes, asked them why they do this) and they feel they are giving the patient the answers they want to hear and that is a good thing. Everyone is happy – except that its a lie to you and I. But this is a part of their perspective of the pregnant patient – that feelings are to be placated. In latter pregnancy and labor, they feel it is okay for the physician to do whatever is deemed necessary and convince the patient that their doctors knows best. They don’t see it as a collaborative relationship, but one where the doctor’s preferences rule. The more I read about how physicians actually view patients (and hang out with them socially), the more I realize how differently they see pregnant people.
To me, the clients are paying me for my experience and in this situation I have direct experience with this careprovider. The dilemma seems to be that the doula has proprietary knowledge about how this physician practices and whether and how she shares that knowledge with her clients – and how to keep confidentiality regarding the physician. In some situations, I will say, “You know, my clients who have had similar birth plans and the same physician, the births just haven’t turned out to be that satisfying for my clients.” I can be very strong in my implications without divulging any details. “They just haven’t been satisfied with the way things turned out, the options and choices and reasoning given by the doctor.” I also use the Models of Birth continuum exercise, so my clients can assess their own philosophy, their careprovider’s philosophy, and how much difference is between them. The bigger the space, the bigger the opportunity they will not be satisfied with the options their chosen careprovider gives them. When approached as a difference in philosophy, its less personal for clients, and easier for them to focus on their options.
I would ask: “Would you be interested in a few questions you could ask your practitioner?” These questions might be, how often does he induce/augment? How often does inductions lead to cesarean birth? By them doing their own research, they can be empowered to make their own choice as a result of her own research. I would not, in any way, to undermine their confidence in their doctor. I would also provide ACOG recommendations. One thing I suggest clients ask, when they might be presented with information that opposes ACOG guidelines is, “Why is my situation different from what ACOG recommends?” Also I cannot say enough about teaching communication strategies ahead of time, including shared decision making.
I love this idea of giving questions o ask the OB/Gyn this gives the client a voice and extra confidence to dig for the answers themselves and not feel intimidated to voice what they want for their birth
The majority of my clients ask me if I have worked with their doctor before and typically ask what my experience with said doctor has been. If these questions were asked, I would definitely share with my client about the previous experiences. If the questions weren’t asked, I would probably speak more generically and warn them about scenarios I have seen where doctors change their tune at 40 weeks.
I don’t typically give info on specific doctors. Like others have said, if they ask a deliberate question about the specific doctor, I would answer them. Otherwise I suggest questions to ask their provider and the hospital during the hospital tour. I also remind them that the choice unltimately belongs to them.
I would let them know that many OB practices often recommend induction near the due date. To be ready to discuss the options, I’d explain what the induction process looks like so so they are aware what they may experience. I’d remind them of all the good things that are happening in the last weeks prior to labor (events of late pregnancy print out) for baby, mom, and the placenta. I’d also explain the opposite argument about why the OB might be concerned and the medical viewpoint. I’d remind them of their questions card and to keep that handy. I’d also look for some articles to share with them about induction so they can read for themselves. I’d remind them to read the “priorities for childbirth” handout. Then when they are faced with the OB visit, they’ll be prepared. They need to make this decision along with the care prrovider they’ve chosen. IF, and only IF, they request or mention they are concerned about their care provider, I’d process that question with them and offer some recommendations.
thank you so much for giving us the opportunity to sharpen our Doula skills – DONA you awesome! I strongly agree with Stacie Bingham… having the client inquire of said dr. about induction rates, C-section rates, induction rates after 40 weeks, motives, outcomes, etc. are all very important questions that can help a client understand what she is facing… self empowerment is important… once she has that info from the OB and comes back with questions or concerns, i would tell all… it is relevant info…
LOVE this topic, Sharon. Thank you DONA International for another great resource and way for us all to learn together and cultivate connections.
I would start by asking my clients how they feel about this recommendation? How is it for them to learn their care provider may not be on the same page with them after all? Once we have considered feelings – I would ask what they think they need. I would like to give them the opportunity to formulate what they value and what action they would like to take before suggesting anything. I always want to give them the opportunity to come to conclusions and action steps themselves. It builds confidence. They may spell out what I would have recommended – asking questions – (as Stacie Bingham mentioned below).
If they are unsure, I would ask “How would it be for you to ask a few more questions?”
When I know a client has chosen a care provider who may be challenging for them based on what they value, I will suggest questions along the way. I move at the speed of trust – once they know I am invested in what matters to them and that I am giving them evidence based information/resources, I can share why they may need to be more assertive and get clarification/commitment early.
I would provide the clients with the new information, presenting it in a neutral way. I would prefer that the client has all info required to make an informed decision. Ultimately, it is her body, their baby, their choice.
When a client mentions that the provider is talking about induction before the edd, I usually do two things 1) evidence evidence evidence 2) share experiences I’ve witnessed with inductions. If the clients asks me specifically if I know whether or not this provider has a high incidence of inductions, I would suggest that they 1) discuss their curiosity with the provider and 2) offer client appropriate questions to take to the provider. I would let the client know that if they are not satisfied or comfortable with the provider’s replies, we can talk about what they would like to do. I would rather the client come to the conclusion that they want to switch providers than recommend or suggest it.
I have a,ways believed that honesty is the best policy and since my clients have hired me to help them, I would suggest, in the nicest way possible that they might want to cobsider looking for a new provider so they can have the birth they want. After I have suggested this to them, it’s up to them if they want to look elsewhere or not. I just couldn’t stand by and let my clients be mislead.
I would just suggest to them that they talk to their provider about the importance of a natural birth without unnecessary interventions. Then they can decide how to proceed from there and if they are comfortable with what their provider says. I would encourage them to be comfortable with their provider and that the provider will support the kind of birth they are looking for as much as possible.
I would ask them how they are feeing about the recommendation. My response would be determined by how they are feeling. If they are unsure about any part, I will offer suggestions of further reading/researching and/or questions to ask at their next appointment. If they still feel supported by their care provider, I would stand by their choice.
What a great forum, thank you! Why would the Dr. Induce so early? Normal gestation is 41 weeks. Giving my client all the facts and experiences of other clients is important. Let her body do what it is designed for.
After discussing the birth plan with the client I would say generically speaking that numerous doctors push for induction as early as 39 or 40 weeks and tell my clients that they should definitely discuss those options with the doctor and let them know they wish to go into labor naturally and avoid induction up to 42 weeks if mom and baby are showing now signs of distress
Professionalism is key here. We know that if the doctor performs as he/she did before that the couple will possibly end up in the same situation as the clients before them and not get the results that they desire. Knowing this, if we look at the information that the doctor is giving, and forearm ourselves with correct updated information, we can then be ready to share with our clients when they ask us for our input. That I believe, is the gist of our ‘job’, not to take over but to forearm our clients so they can make the most informed decisions possible.
Briefly – I would look up evidence-based information on induced labors (without medical needs) at 39 – 40 weeks that provides, if possible, the effects on the labor, the client, the baby, the partner. I would also look up the same information on natural births 40 – 42 weeks. I’d have it in printed form and bring up the subject when appropriate. I would provide them with the printed information. Whatever their feeling re: their “birther” and how they proceed, they have the information in them and on them and I can feel that I’ve given them the tools to make an educated choice.
I immediately put myself in the position of this new mother. If I had hired a doula, I would want her to share her knowledge with me. I think I would have to reassure her that I support her decision with this doctor if she stays with him and then share briefly the experiences I have had with previous clients so she could make an informed choice. I would try to be very professional and not ‘doctor-bash’.